MPTA's Payment Committee is continually meeting with health care professionals and various insurance companies throughout the state of Michigan to keep our members notified of any changes coming and to advocate for our physical therapy professionals. As a benefit to our membership, MPTA members are notified immediately of any policy changes or deadlines to an insurance plan or group.
Not all Payment questions can be treated the same way. Please email [email protected] if you have a specific question as it relates to Payment.
CMS Reverses Most of Its Damaging Coding Editsposted: January 25, 2020
Details remain to be worked out, but the bottom line is that CMS is reversing its decision to prohibit payment for evaluation and certain interventions delivered on the same day — a big win driven by the combined advocacy efforts of APTA, its members, and other stakeholders.
eviCore Clinical Criteria Guidelines - Updated Version Availableposted: January 25, 2020
MPTA has recently been provided an updated version of the eviCore Clinical Criteria guidelines. Click HERE to download the Guidelines.
Notice from BCBSM about Provider Authorization Formposted: January 02, 2020
Updating changes to your Provider Authorization form
Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization form before they can exchange PHI with Blue Cross.
Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 files, you must update your Provider Authorization form. Updating the form ensures information is routed to the appropriate destination. You don’t need to update the Provider Authorization form if your submitter and Trading Partner IDs don’t change.
You should review your provider authorization information if you’ve:
- Joined a new group practice
- Left a group practice and now bill using your own NPI
- Hired a new billing service
- Started submitting claims through a clearinghouse or you’ve changed clearinghouses
- Decided you no longer want to receive 835 remittance files
- Selected a new destination for your 835s
You must update your Provider Authorization form if you’ll be sending claims using a different submitter ID or routing your 835s to a different unique receiver or Trading Partner ID. To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:
- Click on Quick Links.
- Click on Electronic Connectivity (EDI).
- Click on How to use EDI to exchange information with us electronically.
- Click on Update your Provider Authorization Form under EDI Agreements.
If you have any questions about EDI enrollment, contact the EDI Help Desk at 1-800-542-0945. For assistance with the TPA and Provider Authorization form, select the TPA option.
Senate Bill 612 Introduced - Prior Authorization Reformposted: November 13, 2019
We are very excited to announce the introduction of Senate Bill (SB) 612 which seeks to reform prior authorization practices in Michigan. This bill is the result of our collaboration with a large provider and consumer advocacy group coalition called Health Can’t Wait. The legislation is but 1 component of the this campaign that also includes consumer education and collection of patient stories.
The bill is sponsored by Senator Curt Vanderwall (Benzie, Crawford, Kalkaska, Lake, Leelanau, Manistee, Mason, Missaukee, Ogemaw, Osceola, Roscommon and Wexford). The most important parts of the bill that impact physical therapy include:
- Requiring payers to post prior authorization requirements on their public website and be readily available to providers at the point of care
Criteria that are based on peer-reviewed clinical review criteria which:
- Must be based on national association guidelines
- Account for atypical patient populations/diagnoses
- Ensure quality of care
- Be flexible for case-by-case deviation
- Evaluated and updated annually
- Be developed with input from health professionals licensed in the same profession
- Requiring payers to “conspicuously” post statistics about denials and appeals, including the top 10 reasons for denial, on their public website
Please contact your State Senator and State Representative NOW and tell them about the adverse impact that prior authorization is having on our ability to deliver medically, necessary care to our patients. For more information on the Health Can’t Wait coalition and to submit your patients’ stories, visit https://www.healthcantwait.org/
Effective November 1, 2019 - Meridian Medicaid requires pre-treatment authorizationposted: November 05, 2019
Meridian Medicaid now requires pre-treatment authorization, and has implemented eviCore’s Core-Path process similar to BCN and MPB.
Meridian states the authorization may take up to 14 days, but early indicators have shown a much shorter time frame. This was implemented November 1, 2019.
MPTA Announces New Payment Specialist Positionposted: August 19, 2019
In recognition of the ongoing challenges faced by our members related to payment, the MPTA Board established a part-time Payment Specialist position. We are happy to announce that Barbara Herzog, PT will be working in this position. Her full bio is below. To contact Barb with your questions and concerns, email [email protected]. After verifying your membership status, Barbara will respond.
Barbara Herzog, PT - MPTA Payment Specialist
Barbara Herzog has been a physical therapist in Michigan for 38 years after graduating from the College of St. Scholastica, Duluth, MN. She spent the majority of her career in private practice owning a contract/personnel placement company, Private Practice/Rehab Agency, and medical wellness/fitness center and eventually selling those businesses in 2011. During that time, she was active in advancing private practice, fair reimbursement and the recognition of physical therapy services as a profession not only in private practice but in settings such as home care, worker’s comp and auto.
Barbara’s professional membership includes multiple years with PTPN as president, and she has been a member of APTA/MPTA since 1988. She has been continually active with APTA/MPTA serving as Vice President 2009-2010, federal affairs liaison, legislative committee member and payment and policy committee member. She has worked closely with multiple commercial insurance companies, self-insured employers, TPA’s, and other entities to facilitate and negotiate equitable payment and policies for the physical therapy profession in all settings. She attends payer meetings – Worker’s comp, HMO’s, commercial insurance PPO’s, and state funded plans.
Barbara remains a passionate practicing PT, currently working in several practice settings: hospital out-patient, private practice clinic and home health.
Guide to Access BCBSM Provider Manualsposted: August 22, 2018
Following our meeting with BCBSM on May 11, 2018, the MPTA reported that BCBSM was moving to a vendor-based auditing program for its PPO, similar to what is currently being used for its Plus Blue product, starting this summer 2018. BCBSM stressed that this program is not being used as a utilization
management tool. Rather, it is a tool for fiduciary responsibility to ensure that policies and procedures are being followed and will be equally implemented across all health care providers and settings. Providers will be selected for audit based on computerized algorithms. Thus, it is difficult to predict for a given practice whether audit risk will increase or decrease under this new system.
In response to MPTA’s concern about transparency of auditing criteria, BCBSM stated that the criteria are the policies and procedures in the applicable Provider Manuals. However, actually finding and accessing the Provider Manuals can be a substantial challenge. Therefore, MPTA has outlined the requisite steps below:
Log onto the BCBSM website “Provider Secured Services”
Click “webDENIS” (must have webDENIS access)
Choose “Provider Manual”
You will have a choice of 5 different Provider Manuals:
1) BlueCross PPO Provider Manual click to choose
click provider type Independent Therapist or Freestanding Out Patient PT
Search and you will get categories / chapters to choose from. This particular manual is
2) BCN Provider Manual
When you make this choice, you must go through the manual to find the chapters
that refer to therapy.
3) Blue Cross Medicare Plus Blue PPO Provider Manual
4) Blue Cross Medicare Private Fee for Service Provider Manual
5) Blue Cross Complete Provider Manual (for managed Medicaid)
When you choose manuals 3,4 or 5 you must scroll through the index to find the
chapters and pages that refer to therapy. Unfortunately, there is no short cut to specific sections
in these three manuals.
- MPTA Comments on Proposed Home Health Policy Changes - July 10, 2019
- MPTA Email to BCBSM Re Direct Access Resources August 24, 2019
- MPTA Letter to BCBSM July 26, 2019
- MPTA Letter to BCBSM 3.22.19
- MPTA Letter to eviCore - October 15, 2018
- MPTA Email to BCBSM October 15, 2018
- BCBSM Meeting Minutes - May 11, 2018
- Summary of Meeting with BCBSM May 11, 2018
- MPTA Letter to BCBSM April 24, 2018
- MPTA Meeting with BCBSM and eviCore March 9, 2018
- Summary - March 9 Meeting
- Overview of corePath Survey Data
- MPTA eviCore/corePath Narrative Themes
- corePath Survey Data Analysis
- MPTA Letter to BCBSM October 24, 2017
- MPTA Complaint to Michigan Department of Insurance and Financial Services
- MPTA Letter to Senator Stabenow
- eviCore - Update on MPTA Strategies and Related Actions
- MPTA Letter to BCBSM June 30, 2017
- MPTA Letter to Priority Health June 6, 2017
- MPTA Letter to BCBSM May 12, 2017
- BCBSM Minutes from Meeting March 13, 2017
- MPTA Letter to BCBSM March 13, 2017
- MPTA Letter to BCBSM October 17, 2016
- MPTA Letter to BCBSM June 23, 2016
Important Payment Resources
- Code of Federal Regulations
- State of Michigan:
- APTA Resources: