What about the PT benefit?

Where’s the Beef [aka PT visits]?

A new year has just started, and this is the starting of a new and exciting PT/rehab related blog (that I know you are just going to love! Who doesn’t love talking about health care problems and insurance issues?). Being my first real blog post, I wanted to start off strong. Like the Wright Bros, Madame Curie and Elon Musk . . . oh wait, the Wrights crashed horribly for several years, Curie exposed herself to lethal radiation, and Elon, well starting strong has not been his forte (however, pedal-to-the-metal in a Model S – WOWWWWW!) . . . scratch that. Anyway, I still want to start strong! So I have decided to respond to the #1 question I get from physical therapists, occupational therapists and rehab professionals as part of my non-clinical PT work:

“My patient gets X visits a year and they pay for them so shouldn’t they get to use them all?”

In my work with utilization review I see this just about daily; sometimes just in passing, sometimes rhetorically, sometimes sarcastically. I see it in written requests, emails and even clinical notes. I have overheard providers and office staff “educating” their patients that they have a certain number of visits and they should get them, but the mean insurance won’t let them. Most often this question comes loaded with frustration and misunderstanding, both of which are understandable. So it is my goal to address this frustration and misunderstanding.

Health Insurance plans and policies are NOT simple. Methods used to enforce them are NOT simple either. Frustration is warranted. Having been exposed to the utilization side of things, I know that some mistakes are made and some policies don’t always make sense. However, seeing both sides of the coin, it has become a bit more clear that the majority of frustration comes because of misunderstanding. I am by no means a health policy expert, but I am much more an expert now than when I was purely a clinical PT.

Thanks for nothing PT golden years

A major site of confusion is that coverage of physical therapy and rehabilitation has changed greatly in the last 20 or so years. To avoid a massive tangent, basically it has gone from the “golden age” of providers getting paid for anything without question to the current state of meticulous managed care. PBS did a great Frontline on the history of this several years back, I recommend it as homework. Significant changes were often made just within a year or two and each health plan company mutated into different plans and structures. It became very difficult for a provider to keep up with the changes. Often resulting in some providers not even knowing changes happened. Similarly, patients had (and still have) no idea what their policies covered and how. Primarily, the things being noticed were the ones that affected bottom lines: reimbursement, co-pays, fee-schedules.

Of course, all these benefit changes had to be spelled out in policy contracts. Long contracts! When was the last time you snuggled up to the fireplace with a hot chocolate to read an insurance contract? Ok, bathroom reading then? Yah, me neither. Managed care was being applied in many different forms among many different payers year after year.

Prior to the start of managed care, health care spending had exploded in the private sector. Way beyond what the government was spending. Payers noticed, and the struggle to control costs continues today. Most contracts now include provisions that allow the payer ways to manage costs, such as giving an allotment of rehabilitation visits per year; also the use of pre-authorization, utilization review and other types of management of certain benefits. In 2013 Sandstrom et al published findings in the APTA journal of their research into the variability of insurance coverage for PT of just one national payer, BCBS. Two-thirds of plans limited the number of covered PT visits and over 90% even combined PT into a rehab benefit with other professions. This is not a fad. More and more policies are adding managed provisions every year.

Health Insurance is not an allowance

Before responding directly to the question at hand, I would like to remind us of one other thing. Yes, people that have a health insurance policy pay a premium. However, that premium does not directly pay for the services of just that one policy. Every premium paid gets lumped together within the health plan and then services are reimbursed from that pot. That’s right, my premium went to help pay for your infected belly ring treatment, and your premium went to help pay for my partial lobotomy (well, if we have the same insurance provider).  So really your benefit is more of a potential and not an allowance.  This is the same for most types of insurance; home, auto, life, etc.

How about a quick non-PT example: A Mr. Bond (aka James) owns a fancy car. With his “line of work” he is worried something might just happen to this car. He gets a full coverage auto policy from Q Innovation Insurance. One day, as expected, things get a touch out of hand at work. His nice fancy car ends up with a few new holes. Remarkably the engine still works, it still drives. Mr Bond takes the car to Quantum auto body. The shop owner tells Mr. Bond everything will be taken care of through his insurance. Quantum Auto Body assesses the car’s state and figures since Mr Bond pays for his policy he deserves everything he pays for. They send a request to Q Innovation for a complete over-haul including the engine, exhaust and even electrics. Well, upon getting this request, Q Innovation has some questions. They see according to the claim started by Mr. Bond that the main issues are primarily cosmetic, a few panels, maybe a tune up, some paint and polish. They reply to Quantum with a list of what they will cover and pay for as the rest is not covered as it is clearly not needed.. Quantum flies off the handle and contacts Q Innovation. They forcefully point out that Mr Bond has full coverage, he pays for full coverage and he deserves a full overhaul . . . Despite their “good” intentions, is it possible Quantum has crossed an ethical line?

Sorry, but no . . . 

Back to the big question . . . “My patient gets 30 visits a year and they pay for them so shouldn’t they get to use them all?” Especially if that patient has a managed plan, the answer is “no”. Not only are they paying a premium towards a potential benefit, but the actual contract that they pay the premium for likely has several provisions that tack on requirements to access a benefit. So unless there is good evidence to show a real need, then no, they don’t get to use all the visits. 

It is in the contract!

Forward To The Past! (Great Scott!!)

However, of greater concern is how this question reflects the professionalism and ethics of the provider. This is the exact kind of thinking that created the extreme overuse 20-30 years ago. Which in turn started payers down the road of restrictions in the first place. In my experience this is also generally a last effort excuse by a provider that is not willing to put effort into showing a true need of skilled care; or that need has long past.

Now, don’t get me wrong. I am not saying that I agree with and support every action of every health insurance plan or policy. What I do endorse is a professional acting like a professional and agreeing to the contract they enter. If you are not willing to agree with and adhere to the payer’s contract, then why sign it? Why would you agree to anything that you have not read? I can attest to not doing this in my early years. The first clinic I worked for out of PT school just asked for copies of my license and before I knew it I had piles of forms marked where I should sign. I just signed them without even reading; thinking my job was on the line. Every year all us PTs would get a couple others. We never read them. One year we found out that one contract had some very fine details no one read. It was a costly mistake as by signing we agreed to lower reimbursement for the one plan and every plan underwritten by that company.

A funny thing, that physical therapy company is still in business and doing just fine. The patients we saw under those policies were seen for less visits than some others, but most of them did just fine as well. We had to adapt and be smart. We had to talk with those patients and make a plan to do the most good with a few visits. I am far from a perfect therapist. However, the moral of the story in addressing that big question is to be a professional and take charge of your responsibility to really show when skilled care is needed. Get educated on the plans you profess to “accept” and just accept them for what they allow. Don’t take it personally.

However, the moral of the story in addressing that big question is to be a professional and take charge of your responsibility to really show when skilled care is needed.

Don’t fall back on excuses. Work with the patient to really find out what they cannot do in daily life, compare that to their benefit and discuss how far that will take them. You are an awesome therapist! Seeing some patients only once a week or even less just leaves room for more new patients. Trust in the home exercise program you gave out.  Be creative and empower those patients to get more done with less. There is no rule you have to see every patient 3x a week. Focus more on patient encounters a week vs how many visits each patient gets in a week. 

If a patient does not understand THEIR policy make contacting their insurance rep to learn more part of the HEP. Put the decision in their hands with your help. Don’t make anyone out to be a bad guy. Simply explain that their policy only covers so much. They expect the patient to take charge of their recovery. You will help them along the way. You will space out visits to allow for progress; and, if need be, would be honored to help them get beyond that as out of pocket if that is their wish. No one wants to be told they bought bad insurance. For many, they don’t really have lots of options they can afford. Kind of like being back in middle school when that jerk Tommy would point out my shoes were not Nikes!

I hope this gives you some clarity on the big question about annual rehab visits per year. I am sure there will be some that don’t agree and I am ok with that.  I will just refer to you as Tommy.

Let me know your thoughts in the comments below.  Thanks.


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4 thoughts to “The BIG Question In Pre-Authorization

  • Scott

    Many great points ! I totally agree

    Reply
    • awittypt

      Thanks so much Scott

      Reply
  • Elizabeth

    My first day on your site (heard about you from Non Clinical PT). Really enjoyed this, Scott. Looking forward to learning more insight both as to your position but also to how your insight can help me become a better clinician

    Reply
    • awittypt

      Non-Clinical PT site is super awesome isn’t it. Thanks for the kind words. You are always welcome! Be sure to share with your friends.

      Reply

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