Re: Insurance Reform

[Guest guest]

Dr. ,

I believe your suggestion for the physical therapy profession to remove itself

from a traditional third party payer insurance program until a better system

emerges is unrealistic. A mass exodus of the physical therapy profession out of

a traditional health care delivery system would never happen voluntarily or

unanimously.

Secondly, most patients do not care about the insurance complexities relating to

a clinics reimbursement. In general, patients care about 3 main things relating

to receiving physical therapy services: Costs, Convenience and Results.

Costs: Most people will elect to purchase health insurance if provided by their

employer if they consider it affordable (value). In addition to the major

medical coverage, most health insurance plans have some degree of coverage for

physical therapy. People will seek to use their covered services before even

considering paying out of pocket. It is counterintuitive to believe that a

person who is already paying monthly premiums for health insurance would choose

clinic #1 that does not accept insurance if clinic #2 across the street does.

How many of us have already had the experience of patients choosing to decrease

their frequency and duration due to $30.00 per visit copays. Who would elect to

pay even more?

Convenience: People in general will tend to seek a path of least resistance.

Given a choice, most people will continue to go about their daily lives choosing

to avoid change/inconvenience/conflict while at the same having a monthly

premium quietly deducted from their paychecks vs. getting in the middle of a

personal battle between physical therapy providers and insurers. They truly

don't care about our reimbursement issues.

Results: People do not want to hear about our experience or evidence based

practice. They want to SEE results. If we as a profession based what we do

purely on RCT evidence, the practice of physical therapy would look very

different than it currently does. This is another thread entirely!

Back to the original post: I do believe some industry standards could simplify

our end of the business transaction. However, insurance companies don't

currently seem to have any incentive to change (otherwise they would). And as I

said before, I don't believe the average patient cares about our business

issues.

Insurance companies don't want to pay. Patients want to pay as little as

possible. Therapists want more money with less hassle. This is a difficult

equation to solve!

Jon Mark Pleasant, PT

Methodist Medical Center

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> > All

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> > With last week being Super Bowl weekend, imagine referees calling penalties

based upon football rules within their given state. Or worse, having to call

penalties based upon where the player’s out of season residence is. If a

player’s off season residence is California, the referee would have to call

penalties based upon California football rules. If the player resided in

Tennessee, then…, you get the picture. Can you imagine the nightmare and

headache involved in calling a game? With that analogy in mind…

> >

> > I have just spoken with a representative from one of my United States

Senator's office about Federalizing Insurance Laws. The conversation was

extremely generic, as this representative wasn't in tune with Healthcare

Providers and the issues they face. As we spoke, I used acronyms like CMS

(Center for Medicare/Medicaid Services), MAC (Medicare Administrative

Contractor), rs, Intermediaries, ERISA (Employee Retirement Income

Security Act of 1974), etc. When I finished, she was very candid and told me

that she wasn't well versed in what I was talking about. She did provide me

with a contact that is better positioned to discuss provider reimbursement

issues and I have left a message. I have been a proponent of federalizing

insurance regulations to " level the playing field " for providers. But I do not

think I am doing a good job of educating people why I believe this is important.

I wish every single person that reads PTManager would take some time to read

this post. For the most part, Insurance Reimbursement dictates whether you get

paid and how much. The patient comes in the door for your services, but the

patient's insurance company dictates what you have to do, whether you did it

right and how much you are going to get paid to treat that patient. Is this

right or wrong? I think there are as many opinions on this question as there

are readers of PTManager posts.

> >

> > Let me start out by stating that there are 4 Federal Programs establishing

laws governing the healthcare of the people that fall under these Federal

insurance programs (there may be more, but I don't have time to research). The

4 are as follows:

> >

> > 1. Medicare

> > 2. Medicaid (Federally Funded program with State matching funds required)

> > 3. Champus/Tricare (Insurance for Military Personnel and their families)

> > 4. ERISA (Employee Retirement Income Security Act of 1974) I believe this

covers self funded insurance benefit plans. And here is a link if you would

like to read up on it:

> >

> > http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm

> >

> > In addition to the 4 Federal programs, each state has their own set of

insurance laws, governing insurance companies that operate within their state

boundaries. Each year, our Federal Regulations undergo some modifications.

Each year, our state insurance laws undergo modifications. Each year, our

Insurance Companies review their Medical Policies and modify them if they chose

to.

> >

> > Let me first isolate the Medicare program (but I believe the same statements

that I am making for Medicare will probably hold true for the other 3 Federal

Programs..., if not, I am sure someone on this listserv will correct me).

Medicare has a printed medical policy and a series of printed geographic

reimbursements for their services (i.e., the Physician Fee Schedule). Everyone

has access to that policy, and if a provider doesn't understand the why of

something, can pull up this policy and review it. If they don't like something

in that policy, they can protest it, appeal it or accept it and move on/change

their treatment methodology. The same holds true for the other 3 federal

programs. However, I would expect that not everyone encounters the other 3

programs as much as they do Medicare.

> >

> > Now, if a patient comes through your door and has an insurance other than

the ones illustrated above, chances are that you are dealing with an insurance

company that falls under your state law's jurisdiction (unless this patient

resides out of state or was injured on the job in another state..., in which

case that state's laws govern your treatment). All of these insurance companies

have established Medical Policies. At this point I would ask all of you reading

this the following questions:

> >

> > 1. Does your state law formulate a standard for medical policy (and if they

don't, who decides medical policy for insurance companies/beneficiaries)?

> > 2. If not, does your insurance company publish or otherwise make their

medical policy available to you?

> > 3. How many medical policies should you have to know in order to provide

the appropriate medical treatment for your patient?

> >

> > In the past 2 decades, CMS (Center for Medicare/Medicaid Services) has been

undergoing a transformation. In the late 80's, HCFA (HealthCare Financing

Administration) had laws on the books that were being interpreted by multiple

Medicare rs (Medicare Part B-Outpatient Clinics) and Intermediaries

(Medicare Part A-Hospitals) in each state. In each state HCFA had at least one

r and Intermediary under contract to administer their regulations and

provide oversight of their programs. In some states, HCFA had multiple rs

and Intermediaries. Each r and Intermediary was responsible for

interpreting those regulations. In recent years we have seen consolidation of

rs and Intermediaries into MAC's. While I cannot pretend to understand

HCFA/CMS' decision for this consolidation, I suspect it had a basis in reducing

cost and providing more consistent interpretation of the regulations. I know

the WPS (Wisconsin Physician Services) is now the MAC for at least 8 states (4

of which they handle both Medicare A and . The result of this consolidation

has been more consistent interpretation of the Medicare Regulations across both

Medicare A and B settings (Hospitals and Outpatient clinics respectively)

> >

> > Where am I going with all of this? Ask yourself these questions:

> >

> > 1. In addition to knowing the 4 Federal Programs Medical Policy, how many

other medical policies do I have to know within my state boundary?

> > 2. Am I treating a patient that was injured in a Work Related Accident from

out of state? If so, do I know the W/C (work comp) Medical Policy for that

state?

> > 3. Are any of my patients covered under an out of state policy? If so,

what is their medical policy?

> > 4. ***MOST IMPORTANT*** Should Insurance medical policy coverage be

substantially different from one insurance company to the next or, could a

federal policy be generated that could govern 90% of what we do?

> >

> > These issues don't always affect the healthcare provider because they hire

staff to " handle " these issues. But the support staff can chew up a lot of

administrative time digging for answers to these questions. If they don't,

Insurance companies can typically tell patients that the provider knew or should

have known their policy before treatment started.

> >

> > I believe that if we could establish a single Medical Policy or even limit

the numbers of policies, it would save a great deal of healthcare provider time

and money (i.e., reduce expenses). Or, maybe an even better option (which

employers seem to be embracing more regularly), is to push patients over to a

catastrophic policy with a Medical Savings (health savings account) account.

That way the insurance companies have less control and the consumer becomes more

responsible for their healthcare decisions.

> >

> > If you have made it this far in the post, congratulations for not falling

asleep!!! Federalization of insurance laws may not be the answer, but some form

of standarization is. And I do not see 50 states binding together to come up

with a common set of laws or a common medical policy.

> >

> > Jim Hall, CPA <///><

> > General Manager

> > Rehab Management Services, LLC

> > Cedar Rapids, IA

> > 319/892-0142

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