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Changes to Payment by Insurers

Thursday, March 21, 2019   (0 Comments)
Posted by: IPTA Admin
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Changes to Payment by Insurers

Based on communications from our members and the APTA there is little doubt that the insurance industry is working to reduce payment on claims. Therapists in Illinois and across the country are finding initial denials for services based on coding.  These changes in payment policy without notice to the providers have and continue to cause great hardship to the therapists and patients being served.  The IPTA has been having conversations with our members over the last year about this growing problem.


Earlier this week Colleen, Rick Rausch (our payment chair) and I met with Blue Cross/Blue Shield of Illinois in Chicago. Also in attendance were representatives of the Illinois Health & Hospital Association (IHHA) and the Illinois State Medical Society (ISMS) to discuss reimbursement and policy changes that have been impacting all of our members.  The two major issues for our members have largely been a change in calculating payment based on CMS 8-minute rule total minutes and the utilization of the -59 modifier.


We addressed the lack of notice and information to providers regarding these significant changes.  This, coupled with BCBSIL's decision to use Verscend to review and administer claims, caused an enormous backlog and resulting slowdown of payment. 


BCBSIL has worked to resolve the timely payment issue but has found, through review, that the majority of claims utilizing the -59 modifier were not substantiated through documentation.  BCBSIL reported that they have denied over 64% of the claims that included the -59 modifier and, on appeal, only 30% of those appealed were paid. BCBSIL expects to open a portal that will allow providers access to more information about claims status, but in the meantime, encourages providers with questions to continue to contact their representative for help.  Educational materials can be requested on a case by case basis to help providers address documentation and coding requirements.


It has recently come to our attention that Aetna has created a front end edit that will deny claims using a -59 modifier.  They have stated that they may remove this edit if they find that claims are paid on appeal. 


It is vital that therapists familiarize themselves with the documentation requirements and appeal any claims denied by any payor due to the -59 modifier.

To that end, I would encourage you to review the materials that the APTA has created to help manage denials:


APTA Template Letters: Appeals  

- Mike Riley, PT
IPTA President (2016 - 2021)
Member since 1973

As part of our REVITALIZE conference on Saturday, April 6th, APTA Senior Payment Specialist Alice Bell, PT, DPT will be presenting on defensible documentation under direct access, and has promised to include an update on what APTA is doing to address these recent changes with payors.

Today we created a Saturday Special registration option that provides a discounted rate for attendance of just the luncheon and afternoon programming so that members can attend the APTA program.

We will extend registration through Monday morning at 8am so that members can still sign up; however, seating is limited. Register now.

Our association will not defend improper coding by our members,  however we will voice our disapproval of sudden changes in policy that results in an increase in the administrative burden.

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