Robert Hall

 

The payment consortium (PC), a collaborative group of physical therapist leaders dedicated to access to PT for all, is hard at work supporting advocacy efforts for APTA Private Practice and AOPT members. The PC held its second meeting in May, and, among other actions, has also dived in to review and file comments to groundbreaking federal regulations. This blog entry addresses the early administrative burden wins from those activities.

Administrative burden harms patients and their physical therapists by taking time away from patient care and grinding down frustrated physical therapists. Both the AOPT and APTA Private Practice have joined APTA in filing multiple comment letters to federal regulators in February, March, and July, 2023, to better address these issues. These efforts hold the promise to bring about real change to on-the-ground work for physical therapists trying to provide medically necessary care to their patients. 

The first suite of regulatory comments responded to requests from the federal government focused on modifying rules for Medicare Advantage plans (Medicare Part C, formerly Medicare+Choice). Medicare Advantage (MA) is poised to become the dominant funding stream for seniors’ and many disabled people’s health insurance, and the program has fostered explosive enrollment growth before and during the pandemic. MA plans had been investigated by the Office of the Inspector General in 2022, and the report by the OIG noted that plans were denying medically necessary care through prior authorization decisions that denied patients the access to services, including PT, supposedly guaranteed by the program. The federal government proposed in the promulgated rules to rein in certain MA plan practices, and the Payment Consortium responded.

One of the issues that the regulations explored was the new practice of Gold Carding. Gold Carding has become popular in some states and aims to reward practices that comply with clinical practice guidelines by eliminating prior authorizations for practices that meet a certain threshold percentage of care comporting with those guidelines. There are pitfalls to such arrangements, however. To avoid these pitfalls, PTs have argued that Gold card programs regulated by both state and the federal authorities should be built on a basis of 12 average visits before review for all PT services and be based on TINs, not NPIs. Gold carding should also be established with an “opt out” for plans by specialty, so that plans are incentivized to eliminate or restrict gold carding for high cost services. Payers and UM organizations should not use claims data as “evidence of outcomes” to develop their algorithms and approval policy. Payers and UM organizations should also never use failure to achieve gold carding to justify decreased payments. Finally, any gold carding program applied to a practice should be based on accurate and up-to-date clinical criteria and never cost alone. The referenced clinical information should be readily available to the prescribing/ordering provider and the public.

Other comments addressed Medicaid Managed Care (MMC) and the attendant administrative burden created by MMC plans. The comments were filed in early July. At this time, the care of 70% of Medicaid enrollees is funded through MMC arrangements. Plans that contract with states to finance their Medicaid benefits are also imposing unnecessary burdens, not the least of which is triangulation between managed care plans and the State for payment of services provided to enrollees. If one of the entities confirms an enrollee is actually enrolled in the program, the PT practice should never have to bear the burden of care provided if that confirmation was erroneous.

These were of course not the only actions related to PT practice taken by the Payment Consortium. Stay tuned for further actions and a focus on how to implement some of the new protections in federal law. If you need help in pushing back against onerous utilization management with federal, state, or private payers, please contact Payment Consortium staff at rhall@ppsapta.org.