Part 1, Reasons 1-4
“This is not a time for tact”
Certain situations call for just the right amount of tact:
- Trying out a new anatomy based pick-up line at your next rehab conference “You know what muscle causes the lateral rotation of my cervical spine? Your gluteus maximus”;
- Your patient starting to explain their problems with “but you don’t understand MY fibromyalgia”;
- Finally telling that one student in PT school that ALWAYS volunteers to remove their shirt for the teacher it is starting to get a bit creepy!
However, this is not one of those times. This is a subject riddled with misinformation and frustration throughout physical therapy, occupational therapy, chiropractic and other rehab professions. The last thing I want to do is create more of that confusion. So, to this end, I am going to state right now that you may find this article a bit brusque at times. I certainly am not aiming my remarks at anyone provider or group. All I ask is that if you feel these suggestions are a bit too blunt, take a look at your current practice and see if there is reason for that. Maybe, there are a few things you could improve and in turn make your clinical life easier. Sound like a deal?
One more thing. This list (and the part 2 list to come) is based on my experience and that of several co-workers. Together we have reviewed well over 300,000 requests for skilled care in the past 5 or so years. Requests spanning all areas of rehab and all regions of the US. We know our isht. However, a bit of a disclaimer. Each request/authorization/review is going to be different. These tips are meant to be used in general. I cannot guarantee that this information will always prevent you from having cases denied. The goal is that it will help you look more deeply into the requests your office sends and understand why it could have been denied; to then find ways of improving your requests. Don’t come crying to me when your case gets denied (told you I was going to be blunt. Of, course, genuine questions? you can always comment or email).
Ok, well then, without further delay, here is Part One, the first 4, of the top reasons your physical therapy/occupational therapy request for authorization may get denied:
#1 Insufficient or Missing Clinical Info
Of all the reasons for a request for physical therapy to be denied this is the number one reason by far. I know everyone was hoping I was going to say that it is because the devil owns all insurance companies and that clinical review companies just deny to reach certain quotas. While I cannot speak for every single company (or the devil), this is just not true or ethical. These companies are actually under a great deal of regulation. None of you are going to like to hear this, but the #1 reason for physical therapy requests to be denied is because the providers’ office just did not send the requested information. It is that simple.
Some of this can be chalked up to being a new process for a clinic, seeing an out of network plan your not familiar with, or maybe a well-intentioned office worker that starts a request but it does not get finished. This just doesn’t explain all the occurrences of missing key clinical information. There are some rehab provider offices that just don’t want to take the time to learn to send the appropriate information (usually dx, specific dates, objective and outcome measures, goals).
I have seen how time after time some physical therapy, occupational therapy, chiropractic or other medical offices will just continue in ignorance. Some sending nothing more than the patient name, date of birth and little else. Then they wonder why care was denied? They keep this up for years mind you. This is after multiple attempts to educate the providers at these locations. Also, of course, this is after multiple, multiple denials to these offices for the same reason. It is basically impossible to complete a clinical review without clinical information, if the provider cannot get the information to review the review gets denied. Sorry, but this is totally on the providers (well about 99% of the time, on occasion this can be due to fax or computer issues on either end).
#2 Secondary Provider Listed (aka Duplicate Providers) for Same Condition
This reason is slightly less common, but is still regularly seen as a reason for denied care in rehabilitation. Basically how this one works is the patient has a current authorization on file with one provider then a second provider sends a new request during the same time period for the same problem. Most times this happens because the patient is switching providers and they don’t communicate it with their health plan. We can all agree that most patients don’t really understand their health plan, so they generally don’t know to do this.
It does happen from time to time where the patient tries to see two providers at the same time, such as a PT and also a Chiropractor and both would be under the physical therapy benefit. Another instance is when the first provider refers the patient to a colleague in the same clinic for a related condition, or same condition but a different treatment style, at the same time. A good example is sending in one request for land based therapy under one provider and then sending in a second for aquatic therapy under another provider; or a second provider for a specific type of manual therapy, taping, dry needling, you name it. Most health plans do not see this type of dual provider-ship as needed, at least not in the sense that two separate cases need to be created. So in these cases, the second case will be denied. If it is just an issue with a previous provider, usually a phone call from the patient to declare who their provider of choice is will clear things up.
Now wait just a second before you go all Deadpool on me. There is gray area here. There are some dual provider situations that are certainly legitimate. This is generally the case for more complex conditions such as CVA, TBI, SCI, pediatric cases, significant trauma or when two completely unrelated issues need skilled care (like falls prevention and wound care, or shoulder post-op and pelvic floor). If there really is a case for duplicate providers, then both providers will just need to be on point in how they justify it. This is primarily done through each provider having completely different treatment goals, outcomes and functional tracking.
(Unfortunately, there are times when a patient may not even know they have an authorization on file. Most often this is seen when a patient had an orthopedic surgery and the surgeon or hospital group automatically sends in a request for post-op therapy. However the patient has a therapist they want to go to. This therapist sends in a request that gets denied because the hospital group sent one in first. I completely agree that this one is frustrating, but again mostly comes down to the patient not understanding how things work and to tell the hospital group they don’t want PT with them.)
#3 No Documented Functional Loss
A skilled care rehab benefit is generally there to help cover getting a patient back to a certain level of functioning. Not a certain ROM, not a certain level of pain, not a set amount of strength. These do play a part, but the bigger picture is how these affect the ability of the patient in their daily tasks. There also has to be a way to compare this information from patient to patient. Health plans have an obligation to fair coverage for each of their members right (yes, yes roll your eyes if you must)?
Currently, the best way to do this is to use standardized functional outcomes or tools. If you have graduated from an accredited PT, OT or chiropractic school within the last 30 years then you will know at least a few of these. Think LEFS, BERG, DASH, TUG, ODI, Tinetti, NDI, 9-hole Peg, Box & Blocks, etc. Usage of standardized tests such as these have been recommended for many years in just about every peer reviewed clinical practice guideline published. Yet, I still see dozens of requests every day where the provider just does not use them at all. EVER!?! 🤦♀️🤦♂️ They continue to rely on pain, range of motion, strength and subjective findings only. This is not the current standard of practice. This is just stubborn, lazy or both.
I would like to share a recent example if I may. This was the primary information sent from a provider for continued care:
Diana Prince (no, not really) “is very motivated and has been consistent with her HEP. I feel one of her greatest needs for further PT is for manual therapy. She needs joint mobilization to her GH joint to address shoulder impingement. I have been performing MET to her SI joint. Although she is very compliant with her HEP, she would benefit from further progression of her core and hip girdle strengthening as she also has a history of three abdominal surgeries that contributed to core weakness. She has a decrease in thoracic ROM which is contributing to her L shld impingement and lumbar symptoms. Her Tspine ROM has not changed significantly at this point in treatment.”
Despite the length of information sent, there is not one bit of information as to how the patient is doing in daily life. There is nothing to show this patient needs their health plan benefit to pay for continued services in this case. I am not saying the therapy might not help the patient, but has the provider shown that the health plan should continue to pay for services being rendered? For all we know this patient is able to work full-time, go to the gym, go shopping, etc.
Another point to be aware of, most health plan benefits are not meant to pay for services to get the patient back to 100% of their previous ability. This thinking is old-school. You would need to look at each specific plan or policy to know for sure; but a good rule of thumb for most private health plans is to help cover getting the patient back to about 80% of normal and that the patient progresses regularly from the care provided. At this point, the expectation is that the patient will be squared away with a good home program and be able to take it from their. Watch for more on this topic in upcoming posts.
#4 Continued Care Not Supported
Finally, here is where we get to the reason for denial actually coming from the clinical review itself. Something in the information the provider office submitted showed that the patient has progressed to that 80% ability level, has plateaued, is getting worse or continued care is otherwise not supported based on the health plan’s definition of medical need. A few of these other reasons may be non-compliance of the patient, non-evidence based treatments, some progress but not enough to clearly show it is due to the treatment provided (slow progress). If you need more background on this, you can read my previous post on medical necessity.
As a profession we still have a long way to go in understanding that we just cannot treat patients forever and expect their benefit to pay for it. If they want to continue with your services after the health plan denies, great, get them on a cash pay plan. If the patient is at about 80% and is doing most normal tasks of daily life (that does not include sports or recreation) then you should be proud that you did your job well. Open up space in your schedule to help another patient. Empower the patient to be on their own. Then when they have an issue they will come back. If the patient is not doing well, suck it up and understand that you CANNOT HELP EVERYONE. Refer them on or pull up your big boy (girl) pants and explain to the patient frankly,
“we have given it a good try, I am sorry to say this is not helping. I recommend you take a break from PT. Please continue with your HEP and return to your physician if so inclined.”
I really think this is what separates the good providers from exceptionally great providers. Humility to admit that your services are not helping can be difficult, but at times it is the right thing to do. Maybe you can help them find the right service. Just don’t do a disservice in thinking that if you just go another 12, 24, 36 visits that maybe they will turn a corner.
Let me share with you another example from a clinical note:
“Assessment: Pt continues to be limited by mid-back pain, likely related to ongoing deficits in posture and mobility. Limited compliance with his home program since last appointment likely contributes to his increases in symptoms. Patient needs to be more consistent in his home exercises to improve his posture and mobility. Patient will benefit from supervised physical therapy in order to reduce symptoms and safely restore function.”
So the patient is not doing their home program, this means you just give more care?🤦♀️🤦♂️ If a pain patient doesn’t take their pain meds should the doctor just give a new prescription? If you didn’t do your studies in PT school should the professor just have held more classes? If your kid does not clean their room should you just keep cleaning it for them? Patient compliance will also be a topic in the future (boy I have a lot of writing to do) so be sure to come back.
There you have it, the first 4 Top 8 Reasons Your Request for Physical or Occupational Therapy could have been denied. Sorry if it was kind of a hard pill to swallow. Now you know to record and track standardized functional outcomes (really you should have known this already). Actually send in the the information the review company requested. If you don’t know what they want, ask them. Communicate with your patients on if they might be moonlighting rehab-style. If so, you may need to talk with them about it. If they are getting better, don’t be afraid to cut the cord. If they are not getting better, don’t be afraid to cut the cord. There certainly are other reasons for denied cases. I still owe you 4 others in the near future. Just don’t be ignorant, you signed the contract. Reach out, get educated, ask questions of the those that review your requests. Schedule peer calls. Go to provider education events. This is all part of being a professional health care provider.
As always, I welcome your comments and questions or you can reach out via email for additional help.