Highmark to require more pre-authorizations

Some experts disagree with 8-visit 'physical medicine' therapy limit


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Hoping to save money and cut back on what it views as unnecessary treatment, health insurer Highmark Inc. will require prior authorization for certain "physical medicine" therapies, such as occupational therapy and chiropractor services, starting Sept. 1.

Pre-authorization will be required only after the eighth visit for a particular type of service in a calendar year, a limit that Highmark characterizes as sound science based on its own research.

Some therapists and chiropractors, though, say the new policy sets an arbitrary cutoff, creates new administrative burdens for clinics, and by design will hurt patients with chronic conditions who require repeat visits and months of physical treatment.

"They're going to be eliminating care for patients who may need it, [based] on computer algorithms," said John McCarrin, outgoing president of the Pennsylvania Chiropractic Association.

The prior-authorization policy applies to all Highmark members insured through employer-based group policies in Pennsylvania and West Virginia, as well as individual members and Medicare Advantage members.

In researching ways to contain costs and reduce unneeded procedures, "one of the areas that kept coming up [was] physical medicine," said Virginia Calega, Highmark's vice president of medical management and policy.

"It's an area that, when we started looking at our own data, we have a lot of unwarranted variation." That variation includes variations in "patterns of care," particularly on the chiropractic side of things.

The chiropractor's "scope of license [is] fairly broad," doing adjustments, massage therapy, electrical stimulation therapy and more, Dr. Calega said.

"We had a fair number of people getting five, six, seven services" in one visit, she said, with Highmark getting billed for each of them.

The company set the new threshold for therapy and chiropractic visits at eight because Highmark's data show that "nearly two-thirds of members have their needs met and resolved within eight visits," according to its press release.

The company spent about $200 million in 2010 on chiropractic, occupational therapy and physical therapy payment -- $100 million for chiropractic-related services, and almost $100 million more in occupational and physical therapy reimbursement.

Highmark says it believes about a third of those payments could be weeded out of the system and "may not represent optimal utilization," Dr. Calega said.

Highmark, the largest health insurer in the state, is contracting with Healthways, a Tennessee-based case-management firm, to oversee its new policy.

Payers -- both private insurers and government ones, like Medicare -- keep a close eye on chiropractors and physical therapists, largely because of the repetitive nature of their services. Many insurers have been cracking down on chiropractors in particular since a 2005 report from the U.S. Office of Inspector General found that two-thirds of chiropractic claims filed with Medicare were "deficient" -- either because of record-keeping errors or a failure to validate the nature and duration of treatments.

Other insurers have similar policies in place, and some are more restrictive.

New York's Empire Blue Cross Blue Shield, for example, uses health-management company American Specialty Health Networks to monitor chiropractic claims. Empire requires providers to "submit clinical treatment documentation to ASH Networks for review and determination of the medical necessity of further visits" beyond the fifth visit, not the eighth.

Capital BlueCross, in Harrisburg, has been using its own case-management system for physical therapies for two years.

Bethel Park therapist Joseph Agnello, of Agnello Spine & Sports Physical Therapy, acknowledges that insurance company cost-containment policies are a "necessary evil," and that he's been in the business long enough to remember a time when therapists and chiropractors played fast and loose with billing.

But because "we see a lot of people who have failed treatment elsewhere," he is also concerned that many, if not most, of his patients with more complicated cases will have already used up their eight visits by the time they end up in his offices.

He also noted that third-party claims managers, because they are paid by the insurers, "have [an] incentive to decrease utilization of care."

Highmark will be encouraging, but not requiring, therapists and chiropractors to use its new electronic communications platform, NaviNet, to communicate with Healthways and seek the prior authorization. Providers have the chance to appeal the eight-visit limit, but there is no guarantee that Healthways or Highmark will authorize additional covered visits. If that is the case, patients will have to pick up the tab for unauthorized treatments.

Cost-containment measures like these "often leave the patient falling short of their desired health care outcome," said Pittsburgh chiropractor Casey Phillips, who has offices in Bethel Park and on the North Side. He estimated that, to get "our patients pain-free and functioning normally," the majority require more than eight visits.

Therapists and chiropractors also are concerned that the eight "visits" could be eaten up before the eighth date of service, because many clinics bill for multiple types of therapies in the same visit, and that each billed treatment will be counted as a separate visit by Highmark, according to physical therapist Sandra McCuen, the reimbursement specialist for the Pennsylvania Physical Therapy Association.

"They can reach that eight-visit threshold very quickly," she said.

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Bill Toland: btoland@post-gazette.com or 412-263-2625.


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