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It is this time of the year when insurance companies are updating their policies and while some of the policy changes fly under the radar, others do not. As this article is being written there are two serious issues that are being battled jointly by OPTA and APTA .
Payment Policy Report Berni Willis – OPTA Payment Policy Specialist
 • United Healthcare Community (Medicaid) is requiring that a referring physician first secure an authorization for the initial evaluation and reevaluation. What?! We are a Direct Access state! If they can secure this, what stops them and other insurance companies applying this practice to their Medicaid, commercial, etc. plans?
• Anthem has entered into a contract with AIM Specialty Health to manage their authorization process. They have had two failed start
dates with no new start date, while expected payments for services are being denied for payment due to the confusion.
These two issues have been escalated to both the state and federal insurance commissioners . It is very important that we stay diligent watching for new utilization management policies being enforced . We all must be on the lookout for these new policies . Please continue to reach out to us if you receive information from your payers of any other new authorization requirements .
We are all aware (or should be) of the upcoming requirement of the PT/PTA payment differential payment policy that is coming around the corner . Effective January 1, 2020 all billing to traditional Medicare is to include the new CQ modifier when the
care has been provided by a PTA, "in whole or in part" as more than 10% of the service. To be clear, this is by treatment (CPT code), so if the PTA does not provide, for example, manual therapy, then you would not include the CQ modifier. There will be no reduction in fee schedule until January 1, 2022 . APTA continues to work with CMS in guidance of the final language. OPTA has verified with Ohio Medicaid they will not be requiring the usage of the CQ modifier. Watch for continued news to learn if any other payers are going to require the usage of the CQ modifier. Do not use that modifier unless the payer requires the modifier.
In closing, at this time of the year, all physical therapists should assess their insurance contracts with their various payers to understand how much they are being paid in network status . Consider the allowed amount, less other adjustments, such as MPPR, sequestration, and other network reductions . Additionally, the payroll for extra front desk staff
to manage patients' eligibility information and authorization follow ups . What are you really getting paid per unit? (I didn't mention other overhead expenses!) Yearly, it is very valuable to your business to review your contracts and assess if you can afford to remain "in contract" with specific payers.
For more information, contact the OPTA office at:
opt@ohiopt.org.
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