The Dirty Truth About Insurance Plans and PT

If you were to compile a list of phrases that describe physical therapists, one phrase that would be near the top is “I love insurance payers.” Both commercial and federal payers are notoriously difficult to work with, and it is certainly not an unwarranted sentiment.

The provision of effective patient care was impeded by governmental and other third-party (i.E., Insurance) regulations, along with higher patient deductibles and patient financial responsibility. Survey participants also indicated that insurance prerequisites were the primary obstacle for patients seeking care directly, regardless of the availability of direct access at the state level. In our recent State of Rehab Therapy industry survey, it was discovered that rehab therapy professionals identified insurance prerequisites as the primary barrier to patients accessing care directly. Additionally, these requirements frequently pose significant challenges for beneficiaries trying to access rehab therapy services. Moreover, they often create significant hurdles for beneficiaries attempting to access rehab therapy services.

Lacking Data

Of course, managing these conditions would suggest that insurance payers would be hopping aboard the train to PT, as it is a considerably more cost-effective and safer option compared to traditional routes of care like prescription meds and surgery. However, one roadblock is the overall lack of existing data and numerous studies speaking to the effectiveness of physical therapy in treating everything from chronic pain to cardiovascular diseases.

It is happening that, despite the research, the cost and utilization of accessing information service on proprietary data is a big part of why payers have to pay. There aren’t many other words to describe the way in which data outcomes are collected by the end payer. Few commercial payers have used functional limitation reporting as a way to collect data on the effectiveness of therapy services (not because of a lack of trying, but because Medicare doesn’t entirely cover it). However, Brooke Andrus, reported recently as the agency that analyzed and reviewed the FLR program in 2019, stated that they did not find it particularly useful in considering payment reform for therapy services, but they did analyze and review the data internally.

The data shows that providers of therapy must deliver the same information to patients and payers in order to demonstrate the value of their services in the global healthcare industry. According to WebPT’s co-founder and president, Heidi Jannenga, therapists must take matters into their own hands by adding the same data-tracking tasks to their individual to-do lists. It is evident that there is still a significant need for therapy providers to have excellent visibility into outcomes in order to satisfy payer requirements.

PTs aren’t typical specialists.

Generally speaking, patients typically have to pay a hefty copay for each visit to specialties other than physical therapy, whereas PT is a specialty that covers the cost of care for the entire treatment period. However, patients usually need to attend multiple sessions per week for an extended period of time, which can result in a significant financial burden. To justify this expenditure, patients often only see physical therapy specialists a few times a year, under specific and often rare circumstances, making it easier for those patients.

In this PT in Motion article, Matt Hyland, PT, PhD, MPA, CSCS, highlights that on each occasion you visit, they not only impose the increased copayment but also apply it towards physical therapy. All subsequent appointments were included in that one copayment, and whether or not you required surgery, you would be directed to an orthopedist by your primary care physicians and would be subject to the elevated copayment.

Hanging in Specialist Limbo

The problem that has only gotten worse is that insurance plans often require higher copayments, which can be a burden for beneficiaries. This is especially true for individuals who require specialized care. Physical therapists who specialize in the treatment of musculoskeletal conditions typically fall into the category of specialist. Brooke Andrus from WebPT explains in this post how insurance payers categorize physical therapists, which is part of the problem.

This article by Jill Murphy explains that in some cases, the consumer actually pays more than 100 percent of the excess cost for therapy providers. Copays have steadily increased, resulting in insurance companies shifting a greater portion of the treatment cost to the patient in an effort to keep insurance premiums low. That’s why.

Finding Common Ground

Despite the abundant evidence that physical therapy is both clinically effective and cost-efficient, why aren’t insurance payers increasing the accessibility of therapy services? Here’s the real query: there are numerous intricate factors that contribute to the soaring cost of healthcare. The truth is, there are many complex elements that contribute to the escalating cost of healthcare, so it’s simple to dismiss it as a mere money-making scheme on the part of the payers. Ultimately, payers and providers share the same goal: assisting patients in achieving optimal health outcomes and avoiding risky, expensive treatments that could lead to further complications in the future. We are aware of this due to the often challenging credentialing processes that ensure payers engage with providers who meet their standards. Insurance payers exist to grant beneficiaries access to safe, high-quality care, and ultimately, payers and providers share the same objective. However, here lies the great irony in this stereotype: healthcare providers and consumers frequently blame insurance companies for being the “major villain” that congests the entire healthcare system. Considering all of this, it’s no surprise that healthcare providers and consumers often pinpoint insurance companies as the “major villain” that congests the entire healthcare system.

Creating a Costly Conundrum

Overall, the poor health conditions of patients with neuromusculoskeletal issues make it harder for them to achieve optimal outcomes in their care, leading to discouragement among many patients seeking rehab therapy. In particular, the lack of expansions in coverage for rehab therapy services has added insult to injury by increasing out-of-pocket costs, further discouraging patients from pursuing these plans. Additionally, in 2018, those purchasing insurance in the private market only had employer-based health insurance, which resulted in employees paying an average of $5,714 towards their coverage, and an average of $18,764 for family coverage in 2017, an increase of 3 percent from the previous year. In order to stay afloat, therapy clinics, especially those heavily reliant on third-party reimbursements, have had to deal with the recent financial burden shift towards patients, as reimbursements from payers continue to dwindle in recent years.

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Taking the Next Steps

As a therapy provider or advocate, can you begin to discover that shared understanding? How might they establish that common ground? Thus, as previously stated, providers and payers seem to desire the identical objective. Are insurance companies genuinely the adversary? How can rehab therapists assert their interests when it pertains to payment reform? What is the next step in this process?

  • Join the APTA’s initiatives to restrict copayments (and engage with the APTA Action Center); and.
  • Call or write to the legislative powers that be and give them your perspective as someone who is actually in the trenches.
  • The efforts of advocacy seem overwhelming, as several states have removed rehab therapists from their designation as specialists and/or have limited the amounts of copay.

  • Kentucky,.
  • Arkansas,.
  • Connecticut,.
  • Missouri, and.
  • South Dakota.
  • These provider-level interactions, which remain in disagreement rather than alignment, signify the initial progression of the therapy industry in cultivating a constructive alliance with insurance payers. This will emerge as a significant advantage in securing improved payment rates, should you be able to furnish evidence demonstrating the efficacy of your treatment. Moreover, you can commence monitoring your personal outcome data and employ it as a bargaining tool during negotiations and subsequent reevaluations of payer contracts.

    Collaboration is essential in every aspect. Providers can now initiate the necessary changes in perceptions and begin doing things right. Isn’t it true that there are definitely providers who can control reimbursement rates and costs? Without a doubt, insurance companies have a somewhat negative impact on both the provider and the patient, as they are the ones causing financial strain.