UPTA Reimbursement News

In July, 2010, the Utah Association for Home Care published an article of interest regarding proposed changes to therapy service regulations by the Centers for Medicare & Medicaid Services (CMS) for "unintended consequences of new high therapy thresholds above 13 visits." Please Click Here for the Full Article.

What the Cypress Care and Alignetworks Companies mean to my clinic reimbursement…

March 2009

This month has been dominated by questions regarding the Cypress Care and Alignetworks companies. These companies have purchased the OptumHealth (ACN) listings of clinics in our area. These companies have purchased a list of clinics that are in-network with OptumHealth Group. Over the past several weeks you have probably read a letter letting you know of the Cypress Care and OptumHealth agreement. If you did not sign the letter sent to you and opt out of the network you will be considered in. Remaining “in-network” means that you will accept a flat fee of $65 for your workers compensation patients (Utah Labor Commission’s fee is usually ranging from $90 to $110 per visit with much higher reimbursement for the initial evaluation) and have to perform their extra paperwork.

In the clinic where I work, we had a patient under one of these networks. I have made several calls and had several discussions with the Alignetworks group. What essentially happens is that the money that has been mandated to be paid by the Utah Labor Commission will go to one of these groups that, in turn, forces you to do their paperwork (lengthier process than the normal RSA from the Utah Labor Commission) and handles authorizations, etc. Obviously, you will get paid approximately half the amount of a normal workers compensation patient.

They try and get contracts with private insurance groups to manage the #of visits, authorization phone calls, and paperwork. The goal is to reduce the cost of the insurer by number of visits and management. The representative I spoke with made the comment to me, that by being in network they will send more volume my way. However, the patient that entered our clinic picked our clinic because it was close by not because this network sent them.

Anyway, just as with the ACN group you will work harder and see less money. By Utah law our state workers compensation patients have the right to see any willing provider and the fee is set by the Utah Labor Commission. Again, the representative that I spoke with stated that she can direct the companies to send their employees to the preferred clinic. I tend to believe that the smaller the participating network they have the less they will try and play their games in Utah. Please take a look at these companies while they are small and decide if your clinic wants to add the low reimbursement for the one type of patient that we actually see fair reimbursement for our services.

Lance Dougher
advancedmotionpt@yahoo.com

Lengthy Discussion on Coding Issues

February 2009
Click here to download

IMPORTANT MEDICAID UPDATE

November 2008

Important Information about Changes in Medicaid Benefits

Traditional Medicaid Clients

Due to State budget shortages, several Medicaid benefits and service categories will be cut. Beginning November 1, 2008, certain benefits and services will only be covered for children under the age of 21 and pregnant women. Medicaid children under the age of 21 receive additional services through the Children’s Health and Evaluation Care (CHEC) program. Every child who has Medicaid is automatically enrolled with CHEC.

Beginning November 1, 2008, the following benefits and services will not be covered for non-pregnant adults age 21 and older with Traditional Medicaid (purple card):

• Audiology and hearing services including hearing aids and hearing aid batteries.
• Chiropractic Services
• Eyeglasses including frames, lenses and contacts.
• Physical therapy and occupational therapy and speech and language services including those provided by independent group practices, rehabilitation centers, nursing homes and through home health providers.

An exception is made for individuals who have Medicare Part B as their primary insurance plan, only when Medicare Part B will cover the service.

For additional information online, please visit https://health.utah.gov/umb/. You can also call the Medicaid information line at 1-801-538-6155 or 1-800-662-9651.

Summaries of the Older Discussions and Issues

Reimbursement News December 2007

Reimbursement News October 2007

APTA Information Bulletin August 2008