Robert Hall

The Payment Consortium is evolving, establishing new goals, implementing creative strategies, and making your dues work harder to help improve your practice. During its May 20 meeting, the Consortium agreed to focus on expanded and quantifiable goals as well as how to achieve them. Using the Objectives and Key Results model, the Payment Consortium will continue its focus on eliminating administrative burden, improving commercial payment, and helping your state Chapter modify your state’s Medicaid program to help physical therapists provide care to everyone in their communities.

More people had health insurance coverage than ever in 2022 (the most recent data available), but too often that insurance does not provide access to medically necessary care provided by physical therapists. The Payment Consortium is responding to this reality. Our goal in this utilization management space is for patients to enjoy unfettered access to high quality physical care. To achieve this, the Payment Consortium will help PTs across the country by:

  • Key Results
    • Supporting the passage of prior authorization/Gold Card legislation (to include no signed plan of care or prior authorization required by state-regulated commercial payers) in 10 states by 12/31/2026
    • Working to change prior authorization policies with local payers with direct meetings in 25 states by 12/31/2026
    • Supporting State Chapters in passing fair co-pay legislation in 10 additional states by 12/31/2026
    • Developing and making available a webinar to hold payers accountable to contract terms and what steps to take when they do not hold up their end by 12/31/2024 
    • Producing an APTA-AOPT-PPS consensus statement on prior authorization and UM reform principles by 12/31/2025
    • Encouraging payers to follow Medicare’s credentialing process and timelines so that newly licensed providers can provide care immediately through holding claims while credentialing processes (generally 30-60 days) conclude
    • Working to have the big five commercial payers adopt APTA Clinical Practice Guidelines as the primary standard for quality care
  • Initiatives
    • Create prior authorization resources and advisory-support task force to assist Chapters by 12/31/2024
    • Creating fair co-pay resources and an advisory-support task force to assist Chapters by 12/31/2024
    • Establish communication and standing up a learning network for delivery of resources and sharing of best practices with Chapters 12/31/2024
    • Support the Private Payer Medicare credentialing initiative
    • Update and package CPGs in a user-friendly format for providers and payers 
    • Negotiate with the Big 5 payers to incorporate CPGs as the primary standard for quality care 
    • Deliver a consensus statement on Prior Authorization and Utilization Management

Physical therapists reported in 2023 that utilization management is a significant time waster in their practices and has deleterious impact on patient care in a recent APTA survey. Nevertheless, commercial payment is also a significant concern. With Medicare cuts that get reflected in commercial contracts, payment has been decreasing while inflation has soared. This must stop, and the best way for PTs to improve payment is to negotiate their contracts. To Improve Commercial Payment, the objective of the Payment Consortium is payment that results in healthy professionals and businesses. To achieve this, the Payment Consortium will help PTs by:

  • Key Results
    • Supporting 500 PTs in completing a negotiation educational series by 12/31/2026
    • Increasing payment per unit in every region (Northeast, South, West Midwest) as per PPS KPI report by 5% by 12/31/2026
    • Eliminating MPPR payment polices with 20 payors by 12/31/2026 
    • Pushing for the introduction of legislation in 10 States/3 payer contracts that include an annual inflationary update to the fee schedules
    • Supporting the establishment of Joint Operating Committees (JOC) in 4 regions (Northeast, South, West, Midwest) to act as support to local Chapters by assisting states to develop a payment advocacy plan by 12/31/2026
  • Initiatives (Lead)
    • Investigate best payer-payment benchmark database to use for key results 
    • Explore feasibility/legality of a member-reported Payer Scorecard 
    • Develop negotiation strategies educational series 
    • Educate regions in using external reviews for denials 
    • Establish JOC resources and advisory-support task force 

Better payment will help physical therapists meet the rising demand for musculoskeletal care. One of the worst payers are Medicaid programs, but paradoxically, the program covers some of the populations most in need of this care. Medicaid finances the care for four major populations in most states: the disabled, children, pregnant women, and the lowest income citizens. If Medicaid paid better, physical therapy practices might be able to care for some or more of the Medicaid population. To support a revolution in Medicaid payment, the Payment Consortium has set the goal of Medicaid populations enjoying access to physical therapy in their communities. To accomplish this goal, the Payment Consortium will help PTs by:

  • Key Results
    • Advocating for Medicaid payment greater than 90% of Medicare in 10 states by the end of 2025
    • Improving access:
      • Medicaid utilization increases by 20% by the end of 2025, or
      • Increasing the percentage of Private Practitioners that accept Medicaid patients/payment by 20% by the end of 2026
  • Initiatives
    • Translating APTA’s Medicaid payment tool to a percentage of Medicare and establish goals 
    • Determining, documenting and educating Chapters on “best practices” learned from States with the best Medicaid payment 
    • Investigating network adequacy requirement opportunities for legislation to improve access
    • Assisting in the creation of model pediatric access State legislation
    • Determining if states have a mandatory window to review their Medicaid fee schedules and educate Chapters on these timelines so they will be involved in the next rate review prior to any legislative push

The overall goal of the Payment Consortium is to improve your bottom line so you can more effectively help patients in your community. We are excited for the next phase of this work.