Re: Argh...insurance companies

[Guest guest]

I would also involve the Better Business Bureau in your state or local area as

well as report this to your state's insurance commissioner. This is blatant

and should be reported.

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[Guest guest]

Does your state practice act prohibit the use of the term, or the

provision of physicial therapy accept when provided by or under the

supervision of a physical therapist? Our state does (fortunately). If

so, I would point it out to the payer, and to the licensing board(s).

Arslanian

Brigham and Women's Hospital

Boston, MA

> Argh...insurance companies

>

> Hi group

>

> We called an insurance company today to find out the Physical Therapy

> benefits

> for a perspective new patient. The authorization person told us that

> they pay

> for physical therapy if a chiropractor provides it but not if a

> Physical

> Therapist provides it. The person said they really didn't even want

> to pay

> for PT from a chiropractor but they were doing it as a courtesy. We

> said " Do

> you mean that you do not pay for a Physical Therapist to treat with

> Physical

> Therapy but will if a chiropractor treats with Physical Therapy? "

> The

> authorization person said " yes this is right " ...and ended the

> conversation

> with " go figure " ....

>

> Yes...go figure!

>

> The patient has decided to come even if her insurance does not

> pay....and we

> are sensitive to out of pocket payments, but it doesn't excuse the

> insurance

> company from excluding the group that has the name Physical Therapy in

> its

> description...Physical Therapist. We've had many other excuses for

> denial of

> PT many of which we can reverse with additional documentation...but

> this takes

> the cake..

>

>

> Carol Ristau PT

>

>

>

>

>

> ----------------------------------------------------------------------

> --

>

[Guest guest]

Which CPT-4 codes does this insurance company pay for under chiropractics? If all they are recognizing are the physical modalities codes, then you have an opportunity to educate and possible bill under the higher level codes (the ones that truely are PT, neuromuscular re-ed, ther ex,etc.) Many insurance companies are confusing physical modalities with physical therapy. Just a point of reference the next time you speak with an insurance company.

Sheri L. Bjork, PT, MBA

JS Consulting

Argh...insurance companies

Hi group

We called an insurance company today to find out the Physical Therapy benefits

for a perspective new patient. The authorization person told us that they pay

for physical therapy if a chiropractor provides it but not if a Physical

Therapist provides it. The person said they really didn't even want to pay

for PT from a chiropractor but they were doing it as a courtesy. We said " Do

you mean that you do not pay for a Physical Therapist to treat with Physical

Therapy but will if a chiropractor treats with Physical Therapy? " The

authorization person said " yes this is right " ...and ended the conversation

with " go figure " ....

Yes...go figure!

The patient has decided to come even if her insurance does not pay....and we

are sensitive to out of pocket payments, but it doesn't excuse the insurance

company from excluding the group that has the name Physical Therapy in its

description...Physical Therapist. We've had many other excuses for denial of

PT many of which we can reverse with additional documentation...but this takes

the cake..

Carol Ristau PT

[Guest guest]

Doesn't the state licensure protect you from others (even chiropractors) from

practicing physical therapy?????

Debra Gibbs,MHS,OTR

CLRinPHX@... wrote:

> Hi group

>

> We called an insurance company today to find out the Physical Therapy benefits

> for a perspective new patient. The authorization person told us that they pay

> for physical therapy if a chiropractor provides it but not if a Physical

> Therapist provides it. The person said they really didn't even want to pay

> for PT from a chiropractor but they were doing it as a courtesy. We said " Do

> you mean that you do not pay for a Physical Therapist to treat with Physical

> Therapy but will if a chiropractor treats with Physical Therapy? " The

> authorization person said " yes this is right " ...and ended the conversation

> with " go figure " ....

>

> Yes...go figure!

>

> The patient has decided to come even if her insurance does not pay....and we

> are sensitive to out of pocket payments, but it doesn't excuse the insurance

> company from excluding the group that has the name Physical Therapy in its

> description...Physical Therapist. We've had many other excuses for denial of

> PT many of which we can reverse with additional documentation...but this takes

> the cake..

>

> Carol Ristau PT

>

>

>

> ------------------------------------------------------------------------

>

[Guest guest]

Carol:

I would not simply accept this policy from this particular payer. Are you a member of APTA? Does your state have a Reimbursement Advisory Committee or any group which looks at the payment policies and problems with Insurers? These are types of issues where a professional association can be helpful in providing education. It is very possible to change payor policy with the proper education and explanation. APTA needs to know about these types of situations in order to address. It is not uncommon to find " unusual " interpretations of state law and regulation which can be corrected. Don't just accept this response, act to change it.

Ken Mailly, PT

Professional Affairs Representative

aptanj

Argh...insurance companies

Hi group

We called an insurance company today to find out the Physical Therapy benefits

for a perspective new patient. The authorization person told us that they pay

for physical therapy if a chiropractor provides it but not if a Physical

Therapist provides it. The person said they really didn't even want to pay

for PT from a chiropractor but they were doing it as a courtesy. We said " Do

you mean that you do not pay for a Physical Therapist to treat with Physical

Therapy but will if a chiropractor treats with Physical Therapy? " The

authorization person said " yes this is right " ...and ended the conversation

with " go figure " ....

Yes...go figure!

The patient has decided to come even if her insurance does not pay....and we

are sensitive to out of pocket payments, but it doesn't excuse the insurance

company from excluding the group that has the name Physical Therapy in its

description...Physical Therapist. We've had many other excuses for denial of

PT many of which we can reverse with additional documentation...but this takes

the cake..

Carol Ristau PT

[Guest guest]

Ken and others...

We are going to respond to that insurance company as we always do when

something that has to do with payor issues comes up...Many times with

documentation, the Practice guide and other bits of research we can get the

companies to turn around and pay...I just couldn't believe what I heard this

authorization person say and had to share it with the group. I've been a PT

for 24 years and most things don't surprise me but this excuse popped one of

my PT buttons and yes I am in the APTA (just signed up for another

year)......Carol

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[Guest guest]

Does the patient have a copy of his/her covered benefits? Does it conflict

with that the ins. co. told you?

Mark Dwyer, MHA, PT

Kansas City, Kansas

mdwyer1@...

Argh...insurance companies

>Hi group

>

>We called an insurance company today to find out the Physical Therapy

benefits

>for a perspective new patient. The authorization person told us that they

pay

>for physical therapy if a chiropractor provides it but not if a Physical

>Therapist provides it. The person said they really didn't even want to pay

>for PT from a chiropractor but they were doing it as a courtesy. We said

" Do

>you mean that you do not pay for a Physical Therapist to treat with

Physical

>Therapy but will if a chiropractor treats with Physical Therapy? " The

>authorization person said " yes this is right " ...and ended the conversation

>with " go figure " ....

>

>Yes...go figure!

>

>The patient has decided to come even if her insurance does not pay....and

we

>are sensitive to out of pocket payments, but it doesn't excuse the

insurance

>company from excluding the group that has the name Physical Therapy in its

>description...Physical Therapist. We've had many other excuses for denial

of

>PT many of which we can reverse with additional documentation...but this

takes

>the cake..

>

>

>Carol Ristau PT

>

>

>

>

>

>------------------------------------------------------------------------

>

[Guest guest]

In a message dated 2/23/1999 2:24:18 AM Eastern Standard Time,

CLRinPHX@... writes:

<< The authorization person told us that they pay for physical therapy if a

chiropractor provides it but not if a Physical Therapist provides it. >>

Dear Carol and Group - Warning - long post

The post did not mention a few items 1) what type of insurance product

(commercial - employer sponsored, commercial - small group and individual,

worker's comp, Medicare supplement etc) 2) what type of insurance model (HMO,

PPO, POS, Indemnity etc.) We will get to the signifigance of this in a

minute.

In many state Chiropractors have, through effective lobbying, obtained

mandatory coverage of chiropractic CARE. This could be outright coverage or

conditional coverage: " .....if XXXXXX is a covered BENEFIT under an insurance

policy then Chiropractic care is also covered " . Psychologists have used this

effectively in obtaining coverage for certain psychological services if they

are also covered by psychiatrists. And social workers in turn have had

success in lobbying the same way: " if XXXXXX is covered by psychologists,

then it is also madatory to provide coverage for social workers for the same

service. " (assuming all licensing requirements and a fit with pertinent

practice acts.) The issue here may be chiropractic coverage is " in " rather

than PT is " out " . Of course in addition to office codes and x-ray codes most

chiropractors use the 9700 series. (Just called a chiro friend and confirmed

this).

We are all familiar with the BENEFITS BOOK that we get from our employers.

This is usually an abbreviated discussion, for the benefit of the employee, on

what is covered and what is not covered, pre-authorization, days of coverage

etc. This document is usually developed from something you will almost never

see: The CERTIFICATE of COVERAGE. This is a lengthy document detailing all

the legal aspects of what is covered under the policy. The employee does not

have this document, but rather the employer (purchaser of policy).

It may very well be that " physical therapy " or " rehabiltiation " is not a

COVERED SERVICE, because it is not a BENEFIT of the policy. In order to find

out the definition of these terms, you have to refer to the Certificate of

Coverage if it they are not found in the Benefits book. Before " fighting city

hall " it is helpful to find out all the facts of the case: have the patient

bring in the benefit book; get the name of the employer and contact the

benefits manager - request to see the Certificate of Coverage - or have it

available to the employee etc.

As you get deeper in the fray to discover if your clinic can get reimbursed

for PT at your clinic it will be important to know the type of insurance

product and insurance model and how it is regulated by your state. (PPOs are

not necessarily insurance products, and if not, are not regulated by the state

in the same fashion as insurance and HMOs). This will help you in going to

the next step if you find that indeed the person does have coverage for PT -

because it is a BENEFIT of the policy. If the patient does not have coverage

for PT arrangements can be made for private pay if the patient so chooses.

If the patient DOES have coverage for PT, but there is a problem in getting it

approved the patient has the option of 1)calling the employer's benefit

office and getting assistance, 2) calling the insurance company directly and

talking to customer service, or an ombudsperson, 3) calling the referring

physician and asking for guidance. Or the patient can let the PT clinic

handle the inquiries. A combination of both may be in order.

The way I would approach this problem is to get all the information necessary

- then determine what is the best approach, and who is to be involved.

The different insurance models will also give an indication as to how the

product is regulated in your state, and if there are grievance procedures for

patients.

" Employers purchase what their employees want, and what the employers can

afford " : The American Rehab Association together with the Rehab Section

of the American Hospital Association engaged the SRI Gallup Hospital Market

Research division in 1989 to research 5 major referral groups (patients,

physicians, employers, unions, and commercial insurance) on their opinions of

medical rehabilitation. The research demonstrated a basic lack of knowledge

of rehab and therapy for all groups that were scientifically surveyed. During

the research process with unions we learned that " rehab " did not even hit the

radar screen of necessary covered health benefits from a union negotiation

perspective. Within employer groups we found similar. Employees preferred

items that were of immediate importance and concern, most notably maternity

coverage and mental health coverage, as well as catastrophic.

Along those same lines, in 1994-5 I started the Medicaid HMO at Tampa General

Hospital as well as the self-insured employee PPO (7000 lives). I personally

met with employees around the clock and polled them regarding the covered

benefits they most wanted to see on the menu: (keeping in mind that TGH has a

60 bed free standing rehab hospital, 5 hospital rehab clinics and 3 offsite

rehab clinics), the only employee who had an interest in rehab was an employee

who's son had a head injury 5 years previous and wanted the safety net of

continued rehab. The most significant items that our employees expressed

concern over were pediatric coverage for well babies and the network,

maternity coverage, mental health coverage, chiropractic coverage and numerous

wellness benefits. While rehab was, of course, incorporated as a benefit, it

is not uncommon for this type of thing to happen when an employer gets

employee participation, and then tries to purchase what his employees need. I

had a patient a few years back that was a T-6 para, no wheelchair could be

purchased. The employer (a small employer who obtained insurance through a

State subsidized purchasing co-op) purchased a policy that did not include

DME. Remind me to tell you how far the social worker and PT on this case

stuck their feet in their mouths " raising hell " . The State Medical Director

of this HMO called me personally (as the Administrator of Managed Care) and

suggested that employees of the hospital not treat " customers " in this

fashion, particularly when they don't know the facts, and the policy

coverages. " He was much more gracious with me than our rehab folks were with

his staff.

I have been actively involved in insurance groups and case management groups

since the early 1980's. I have learned all these lessons either the hard way,

(above) or by being willing to listen and understand the industry we seek to

" sell to " . I enjoy the challenge of doing this, and have trained others who

have worked for me to enjoy it as well. It is hard work, but worthwhile. You

will soon learn which battles to fight, and best to arm yourself for the

battle.

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