Happy 5th BDay to my fav early morning coffee shop, @dojocoffee. Free small coffee with any purchase in celebration.
252 days ago
RT @MariahGardner: If you want the world to make a little bit of sense, sometimes you just have to presume that people are off their meds.
255 days ago
@ImTheQ Top news story in Memphis: "Man calls 911, demands tacos" No doubt
255 days ago
Reimbursement for Direct Access to physical therapy services
is nothing if not variable and for all intents and purposes, mostly
non-existent. Some states have providers
than cover services without a previous referral, but most do not. This stands in stark contrast to practice
acts, where the majority of states permit patients to physical therapy services
without a referral. So the question
becomes, if it is legal to access therapy services without a referral, why is
this not covered by payors? The answer
to this question lies in complicated political forces, and that some insurance
providers regularly operate outside the realm of reason. That said, we can look at events in New
Jersey to shed some light coverage for Direct Access.
Dr. Robertson, the
author and publisher of this blog has been kind enough to invite me to provide
some commentary on how the efforts now underway in New Jersey relate to
reimbursement in general and Direct Access specifically. As a matter of full disclosure, I am the
current President of the New Jersey Society of Independent Physical Therapists
(NJSIPT) which is the organization currently promoting the legislative efforts
noted above. It should also be noted
that as the invited author of this article that any opinions expressed in this
article are solely mine and do not necessarily represent the opinions of the
NJSIPT.
There is probably no single more complex or controversial
issue in health care than reimbursement and a full treatment of this issue is
not possible in a blog article. That
being said it does deserve continued exposure, exploration and discussion and
that is the spirit in which I am approaching this topic.
The complexities of reimbursement arise from an abyss of the
highly varied payer policies of profit driven commercial payers, a heavily
regulated Medicare program, the compendium of state regulations regarding
provision and payment for services and an entire medical industry struggling to
survive in a competitive environment where margins are extraordinarily thin or
non-existent.
As a practicing clinician and private practitioner it is
from the perspective of standards by which I view these legislative
efforts. As the healthcare industry has
consolidated, there has been a concomitant decline in reimbursement as the
insurers increased their stranglehold on the marketplace. Despite this, healthcare costs for
musculoskeletal care have steadily increased. Over the past few years as draconian cuts in reimbursement approaching
60% have put my colleagues and I on the verge of financial collapse, it became
evident that a severe conflict had developed pitting compliance with practice
standards at direct odds with remaining financially viable. The question was how to rectify this
imbalance. The answer was legislatively. This was confirmed at a recent legislative
committee hearing where a member of the committee commented that it was the
purpose of the legislature to ensure fairness when one party utilizes its
position to the detriment of others.
In short this legislative effort in NJ seeks to ensure that
providers are compensated fairly based on prevailing fees as determined by the
state, that barriers to access are removed by ensuring that third party payers
pay for medically necessary services when sought by consumers without a prior
referral from a physician and that payers pay providers their share of the
liability directly without regard for network participation status.
Although there is great variability as to what
“Direct Access” means depending on the various state practice acts and other
statutes, as previously mentioned in this blog by Dr. Robertson one of the
greatest barriers to the actualization of “Direct Access” to Physical
Therapists is the lack of coverage by third party carriers. The legislation currently pending in New
Jersey provides for the coverage of Physical Therapists’ services when accessed
directly by consumers. Considering the
mounting evidence that medical costs are reduced when Physical Therapists’
services are accessed directly I am certain that all interested parties will
realize benefit from this legislation including the third party payer
community.
Reimbursement for Direct Access to physical therapy services is nothing if not variable and for all intents and purposes, mostly non-existent. Some states have providers than cover services without a previous referral, but most do not. This stands in stark contrast to practice acts, where the majority of states permit patients to physical therapy services without a referral. So the question becomes, if it is legal to access therapy services without a referral, why is this not covered by payors? The answer to this question lies in complicated political forces, and that some insurance providers regularly operate outside the realm of reason. That said, we can look at events in New Jersey to shed some light coverage for Direct Access.
Dr. Robertson, the author and publisher of this blog has been kind enough to invite me to provide some commentary on how the efforts now underway in New Jersey relate to reimbursement in general and Direct Access specifically. As a matter of full disclosure, I am the current President of the New Jersey Society of Independent Physical Therapists (NJSIPT) which is the organization currently promoting the legislative efforts noted above. It should also be noted that as the invited author of this article that any opinions expressed in this article are solely mine and do not necessarily represent the opinions of the NJSIPT.
There is probably no single more complex or controversial issue in health care than reimbursement and a full treatment of this issue is not possible in a blog article. That being said it does deserve continued exposure, exploration and discussion and that is the spirit in which I am approaching this topic.
The complexities of reimbursement arise from an abyss of the highly varied payer policies of profit driven commercial payers, a heavily regulated Medicare program, the compendium of state regulations regarding provision and payment for services and an entire medical industry struggling to survive in a competitive environment where margins are extraordinarily thin or non-existent.
As a practicing clinician and private practitioner it is from the perspective of standards by which I view these legislative efforts. As the healthcare industry has consolidated, there has been a concomitant decline in reimbursement as the insurers increased their stranglehold on the marketplace. Despite this, healthcare costs for musculoskeletal care have steadily increased. Over the past few years as draconian cuts in reimbursement approaching 60% have put my colleagues and I on the verge of financial collapse, it became evident that a severe conflict had developed pitting compliance with practice standards at direct odds with remaining financially viable. The question was how to rectify this imbalance. The answer was legislatively. This was confirmed at a recent legislative committee hearing where a member of the committee commented that it was the purpose of the legislature to ensure fairness when one party utilizes its position to the detriment of others.
In short this legislative effort in NJ seeks to ensure that providers are compensated fairly based on prevailing fees as determined by the state, that barriers to access are removed by ensuring that third party payers pay for medically necessary services when sought by consumers without a prior referral from a physician and that payers pay providers their share of the liability directly without regard for network participation status.
Although there is great variability as to what “Direct Access” means depending on the various state practice acts and other statutes, as previously mentioned in this blog by Dr. Robertson one of the greatest barriers to the actualization of “Direct Access” to Physical Therapists is the lack of coverage by third party carriers. The legislation currently pending in New Jersey provides for the coverage of Physical Therapists’ services when accessed directly by consumers. Considering the mounting evidence that medical costs are reduced when Physical Therapists’ services are accessed directly I am certain that all interested parties will realize benefit from this legislation including the third party payer community.
Mark F. Schwall, PT