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.

Payment News:
 

Senate Bill 612 Introduced - Prior Authorization Reform

posted: 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/

 

 

BCBSM - Survey to provide feedback on eviCore utilization management services

posted: November 05, 2019

BCBSM and eviCore prior authorization: Survey opportunity to provide feedback
BCBSM posted a notice in The Record that they are seeking feedback on their utilization management services. To take the survey CLICK HERE. The survey will stay open until December 31.

 

Effective November 1, 2019 - Meridian Medicaid requires pre-treatment authorization

posted: 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. 

https://www.evicore.com/resources/healthplan/meridian-wellcare

 

MPTA Members Participate in the APTA State Policy and Payment Forum

posted: September 23, 2019

MPTA Members participatedin the APTA State Policy and Payment Forum (SPPF) on September 14.  

 

John Zubek provided these notes about the experience~

A first timer’s perspective attending the State Policy and Payment Forum

OVERWHELMING support! For our patients, for our profession. That’s the message I hear while sitting in a room of a few hundred Physical Therapy representatives from every state in the U.S. As I looked around, I saw clinic owners, administrators, lobbyists, chapter presidents, payment specialists and staff physical therapists. Here are few of my takeaways from the Forum:  

  • The APTA is expending an enormous amount of expertise, effort and time influencing legislation and reimbursement rules for the benefit of our patients.  
  • It is important that we meet with other state chapter representatives and learn from their successes and failures.  
  • Our dues and donations really do help MPTA representatives extend and expand our voices. 
  • I experienced genuine optimism for the future of our profession and the value we provide to the patients we serve.  
  • The State Policy and Payment Forum was truly an eye-opening experience and an important wake up call to stay involved.  

 

Those that attended are pictures below left to right:  John Zubek (Leg Ctte), Barb Herzog (Payment Specialist), Jena Colon (Leg Director) and Karen Frederick (Shorelines Editor and member of the APTA Public Policy and Advocacy Committee - PPAC).  

 

MPTA Announces New Payment Specialist Position

posted: 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.

 

 

MPTA Meeting with BCBSM July 30, 2019

posted: August 01, 2019

The MPTA Payment Committee met with BCBSM on July 30, 2019.  We were able to openly discuss key issues in regards to eviCore prior authorization as it relates to criteria for neurological conditions, orthopedic conditions, and complex cases. The eviCore neurological pathway was implemented June 1, 2019 with few errors according to eviCore representatives. We welcome your input as to any difficulties you have had with prior authorization for neurologic conditions. MPTA continues to pursue alternatives to the current UM program by advocating for value-based payment structures and/or a change from prior authorization to outlier management models.

Payment for services under Direct Access is discussed at each meeting with BCBSM. We were asked to better define the parameters of our state practice act and law, national trends and where Federal law does have impact, and CMS recognition of Direct Access. MPTA will be providing BCBSM with available data. 

Regarding provider categorization, it was confirmed that they are shifting to a single BCBSM tiering model for categorization. This includes categorization based on percentage of peer mean utilization adjusted for age, gender, and diagnosis. Although MPTA remains concerned about categorization based primarily on utilization with minimal risk adjustment, the MPTA believes this change is beneficial as it streamlines categorization into a single process across all BCBSM/BCN products. This is effective 01/01/2020 for PPO, MA/PPO, and BCN/BCNA.  Category notification is delayed until new tiering is implemented, which will then be issued bi-annually January and July.  Updates are available on WebDenis and letters to providers will be mailed in February 2020.  Expect to remain in your current categorization until January. 

Please note MPTA correspondence with BCBSM found on the Payment Resources page

 

 

Guide to Access BCBSM Provider Manuals

posted: 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

          for therapies.

      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.

 

 

 

Public Health Code Amended to Allow Nurse Practitioners to Prescribe Physical Therapy - Effective April 9, 2017

posted: April 24, 2017

The Physical Therapy Section of the Public Health Code has been amended to allow Advanced Practice Registered Nurses to prescribe physical therapy:

 

PUBLIC HEALTH CODE (EXCERPT)
Act 368 of 1978

***** 333.17820.amended THIS AMENDED SECTION IS EFFECTIVE APRIL 9, 2017 *****



333.17820.amended Practice of physical therapy or physical therapist assistant; license or authorization required; engaging in treatment with or without prescription of certain license holders; use of words, titles, or letters.

Sec. 17820.

(1) An individual shall not engage in the practice of physical therapy or practice as a physical therapist assistant unless licensed or otherwise authorized under this part. Except as otherwise provided in this subsection, a physical therapist or physical therapist assistant shall engage in the treatment of a patient if that treatment is prescribed by a health care professional who is an advanced practice registered nurse as that term is defined in section 17201, or who holds a license issued under part 166, 170, 175, or 180, or an equivalent license issued by another state. A physical therapist or a physical therapist assistant may engage in the treatment of a patient without the prescription of a health care professional who is an advanced practice registered nurse as that term is defined in section 17201, or who holds a license issued under part 166, 170, 175, or 180, or an equivalent license issued by another state, under either of the following circumstances:

(a) For 21 days or 10 treatments, whichever first occurs. However, a physical therapist shall determine that the patient's condition requires physical therapy before delegating physical therapy interventions to a physical therapist assistant.

(b) The patient is seeking physical therapy services for the purpose of preventing injury or promoting fitness.

 

 

(2) The following words, titles, or letters or a combination of words, titles, or letters, with or without qualifying words or phrases, are restricted in use only to those persons authorized under this part to use the terms and in a way prescribed in this part: "physical therapy", "physical therapist", "doctor of physiotherapy", "doctor of physical therapy", "physiotherapist", "physiotherapy", "registered physical therapist", "licensed physical therapist", "physical therapy technician", "physical therapist assistant", "physical therapy assistant", "physiotherapist assistant", "physiotherapy assistant", "p.t. assistant", "p.t.", "r.p.t.", "l.p.t.", "c.p.t.", "d.p.t.", "m.p.t.", "p.t.a.", "registered p.t.a.", "licensed p.t.a.", "certified p.t.a.", "c.p.t.a.", "l.p.t.a.", "r.p.t.a.", and "p.t.t.".

Section 17201:

Sec. 17201. (1) As used in this part:

(a) “Advanced practice registered nurse” or “a.p.r.n.” means a registered professional nurse who has been granted

a specialty certification under section 17210 in 1 of the following health profession specialty fields:

(i) Nurse midwifery.

(ii) Nurse practitioner.

(iii) Clinical nurse specialist.

PUBLIC HEALTH CODE (EXCERPT)
Act 368 of 1978

***** 333.17820.amended THIS AMENDED SECTION IS EFFECTIVE APRIL 9, 2017 *****

 


333.17820.amended Practice of physical therapy or physical therapist assistant; license or authorization required; engaging in treatment with or without prescription of certain license holders; use of words, titles, or letters.

 

Sec. 17820.

(1) An individual shall not engage in the practice of physical therapy or practice as a physical therapist assistant unless licensed or otherwise authorized under this part. Except as otherwise provided in this subsection, a physical therapist or physical therapist assistant shall engage in the treatment of a patient if that treatment is prescribed by a health care professional who is an advanced practice registered nurse as that term is defined in section 17201, or who holds a license issued under part 166, 170, 175, or 180, or an equivalent license issued by another state. A physical therapist or a physical therapist assistant may engage in the treatment of a patient without the prescription of a health care professional who is an advanced practice registered nurse as that term is defined in section 17201, or who holds a license issued under part 166, 170, 175, or 180, or an equivalent license issued by another state, under either of the following circumstances:

(a) For 21 days or 10 treatments, whichever first occurs. However, a physical therapist shall determine that the patient's condition requires physical therapy before delegating physical therapy interventions to a physical therapist assistant.

(b) The patient is seeking physical therapy services for the purpose of preventing injury or promoting fitness.

(2) The following words, titles, or letters or a combination of words, titles, or letters, with or without qualifying words or phrases, are restricted in use only to those persons authorized under this part to use the terms and in a way prescribed in this part: "physical therapy", "physical therapist", "doctor of physiotherapy", "doctor of physical therapy", "physiotherapist", "physiotherapy", "registered physical therapist", "licensed physical therapist", "physical therapy technician", "physical therapist assistant", "physical therapy assistant", "physiotherapist assistant", "physiotherapy assistant", "p.t. assistant", "p.t.", "r.p.t.", "l.p.t.", "c.p.t.", "d.p.t.", "m.p.t.", "p.t.a.", "registered p.t.a.", "licensed p.t.a.", "certified p.t.a.", "c.p.t.a.", "l.p.t.a.", "r.p.t.a.", and "p.t.t.".

 

 


Michigan Medicaid
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  • MPTA Comments on Proposed Home Health Policy Changes - July 10, 2019

MPTA Correspondence Re: eviCore
[Click to Login and View]

  • 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

Medicare Resources

Medicare Claims Update

Fiscal Intermediaries (FI's) process Medicare claims for services provided in facilities such as Hospitals, Skilled Nursing Facilities (SNF's), Outpatient Rehabilitation Facilities (ORF's), and Comprehensive Outpatient Rehabilitation Facilities (CORF's). These FI's have web sites that provide a vast amount of information regarding Medicare coverage and billing. Your billing office will know the identity of the FI that processes your claims.

United Government Services (UGS) is the largest Medicare Part A Intermediary processing over 30 million claims nationwide each year. UGS serves customers in (insert association's state MI or WI) as well as many other states. The following UGS website contains valuable information that includes: the publication "Physical Therapy, Occupational Therapy and Speech-Language Pathology Outpatient Services Educational Update", Frequently Asked Questions (FAQs), Local Medical Review Policies, Medicare Memos (the monthly newsletter from UGS), links to Centers for Medicare and Medicaid (CMS) websites and more.

Medicare Links

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