Posted on January 5, 2016 by Chapter Staff
Originally Published in HAPTA’s e-Newsletter, What’s HAPTAnin’ – January 2016


2015 APTA State Policy and Payment Forum – Denver, CO

September 19-21, 2015

By Patti Taira-Tokuuke, Payer Relations Co-Chair

From a Payment perspective, the takeaways from the 2015 forum are that many states are facing very similar situations that we have in Hawaii:

  1. Increasing out of pocket (cost sharing) expenses for the patient – in some states they are seeing $70-100/visit co-payments (more than what the insurance company was paying the PT)
  2. Greater use of Utilization Management/Utilization Reviewers (UM/UR) by 3rd parties, meaning insurance companies hire UM/UR folk to take a look at your documentation and decide whether you should get paid (some retrospectively, some concurrently and some prospectively – basically what HMSA does with Landmark). Interesting to point out was that insurers must show that 85% of what they collect in premium dollars go to Medical Care for the patient. If they do an internal medical review it’s considered “administrative cost”, if they use a 3rd party to review, then it’s considered “Medical Care cost”.
  3. States are seeing decreasing fee schedules for State Work Comp and Medicaid with increased administrative burden with paperwork for pre-authorizations as well as different interpretations of the rules.
  4. Silent PPOs due to the consolidation of health insurance companies like Aetna and Humana, Aetna and Coventry, Anthem and Cigna. Because many insurance companies on the mainland have merged or are in the process, you will probably be seeing some contract addendums sent to practice owners. Watch the fine print, you may think you are just re-signing a PPO agreement, but some of these plans also offer motor vehicle and WC plan lines and so you will also be agreeing to a PPO fee schedule instead of our state WC/MVA fee schedule (we already see this with Contract Claims Services Inc and Multi-Plan in Hawaii)
  5. Some states are just starting to see MPPR reductions and Functional Limitation reductions for Medicare Advantage plans as well as NON-MEDICARE plans (I have one reported case of a NON-Medicare plan making MPPR adjustments to a PT claim). We are just starting to hear about “0 payment due to not having Functional Limitation G-codes” with MdX Hawaii (a 3rd party administrator for Humana and UHC/AARP). So, if you are not using the Functional Limitation G-codes for these payers in Hawaii, you will start to see “0” payments. They have also threatened to do retrospective reviews on the functional limitation codes and they may be asking for money back. YIKES!!! I have APTA researching this issue with Advantage Plans.
  6. Finally, there was an Open Town Hall meeting on the Alternative Payment Model that CPT/AMA are expected to launch for physical therapy codes (97001 and 97002) in January 2017 – stay tuned how that will play out as well as if there will be changes with the other 97000 series codes (like Ther ex and Ther activity, etc.) and what the RVU for the new codes will be.

If you start to see any of the above payment issues (#1-5), then please contact your Payer Relations Co-Chairs: Patti at or Shawna Yee at