Resources for your physical therapy practice are a top priority for the MPTA. Please email us with suggestions for the information you would like to see added to our MPTA website.
The MPTA Patient Action Center portal is now available! This portal will allow patients to quickly and easily write letters to BCBSM about their negative experiences. CLICK HERE to access the portal.
If your patients experience delays or other barriers to necessary care because of eviCore, they should be encouraged to call the number on the back of their ID card. If the BCBSM Customer Service Representative determines it is a complaint/grievance, they will forward it according to BCBSM procedures.
You should also encourage them to access the MPTA Patient Advocacy Action Center portal. This will allow patients to use a template letter or customize their own letter, and will allow us to track the scope and extent of the problem. BCBSM may follow-up with patients about their experiences, so please prepare them for that possibility and encourage them to freely share their frustrations.
MPTA is especially concerned about the potential for errant determinations of medical necessity by eviCore, who is required to ensure their determination is consistent with general Medicare standards. According to BCBSM: “If at any time there is a dispute with the meeting of medical necessary, the provider can always request an appeal; for pre-auth the appeal goes to the MA PPO area for appeals at BCBSM and will be reviewed in full.” Please email firstname.lastname@example.org to let us know how frequently you are using this appeals process and whether you feel it is timely and effective.
Please also contact MPTA if you are experiencing problems with your Provider Category (A, B, or C). We have heard from members who have been mis-categorized and are being subject to unnecessary procedures with eviCore.
The practice of physical therapy is governed by various sets of laws, regulations, policies, and guidelines. It is important for physical therapists and physical therapist assistants to be familiar with them and to understand when each is applicable to a given practice setting and/or specific patient. They include:
State Law. The practice of physical therapy is legally regulated at the state level. In Michigan, the Public Health Code is state law. The Administrative Rules written by the Michigan Board of Physical Therapy provide details and interpretation of legislative intent, and are as binding as state law. Compliance with both is required for all settings and patients at all times. Violations of state law can result in sanctions against your license.
Michigan Public Health Code General Provisions:
Michigan Public Health Code Part 178, Physical Therapy: http://www.legislature.mi.gov/(S(s1hvtjgnvvp2pive3db5cuzd))/mileg.aspx?page=getObject&objectName=mcl-368-1978-15-178
Michigan Board of Physical Therapy Administrative Rules: http://w3.lara.state.mi.us/orr/AdminCode.aspx?AdminCode=Department&Dpt=LR&Level_1=Bureau+of+Professional+Licensing
Information on filing a complaint against another licensee:
Third Party Payer Regulations/Contracts. Billing a third party payer for care provided to one of its beneficiaries explicitly attests to your compliance with all of the third party payer's regulations. The penalty for inappropriately billing for services is insurance fraud. Some consider this the most challenging aspect of practice given the wide variety of payer regulations and contracts. Below are links to key regulations for Medicare and Medicaid. Be sure to be familiar with all private payer contracts to whom you bill for services.
Medicare Benefit Policy Manual (See especially Chapter 15, Sections 220 and 230, as well as other Chapters relevant to your specific setting)
Michigan Medicaid Provider Manual (see especially Outpatient Therapy Section 5.2 as well as therapy sections for other settings)
Reporting Medicare Fraud and Abuse:
Reporting Michigan Medicaid Fraud and Abuse:
Professional Practice Standards. The American Physical Therapy Association (APTA) is the exclusive professional association that supports the profession of physical therapy. It sets forth policies and positions regarding best practice and helps establish the prevailing practice standards. Although adherence to all APTA policies and positions is not required, it is strongly advised. In the event of a complaint or lawsuit filed against you, APTA policies and positions will be used to judge your actions by the Michigan Board of Physical Therapy and in a court of law through expert witness testimony.
Facility Policies. Each practice setting/facility has policies and procedures for the provision of care to patients. As with professional practice standards, facility polices are not legally binding. However, if there is a malpractice claim against you, your deviation from any established policies or procedures will be used to judge your actions.
Your Personal Scope of Competence. Although this is addressed in the General Provisions of the Michigan Public Health Code and is therefore a legal requirement, it bears repeating: No matter what your license allows you as a PT/PTA to perform legally, you should not perform any aspect of physical therapy practice that you personally are not trained or competent to perform.