SDPTA Meets with Wellmark On May 14th, members from SDPTA met with representatives from Wellmark to discuss issues regarding reimbursement for physical therapy services. Tom Reding, PT, the local reviewer for PT claims, extended the invitation to the SDPTA Executive Board to represent South Dakota PTs. Tom and one staff represented the SD office, while four representatives from the regional Wellmark office in Des Moines attended, including the Medical Director, and Pam Duffy, PT, the Iowa PT reviewer/consultant. Allen Holm, Becky Thorp, and Bill Meredith represented the SDPTA Board. Karl Kirsch and Bump Anschutz from the Reimbursement Committee had unexpected family conflicts. Two PT’s from AccuCare PT of Sioux Falls filled these two spots to follow-up with member Sue Creel’s concerns.

The “Agenda” of issues reflected members’ concerns as summarized by Karl and Al. Those issues and the general discussion included:

1. Inability to bill US/Estim on the same visit. Modifiers (59) cannot be used on the initial billing to identify when two modalities were performed separately, and not in combination. We had proposed that this would eliminate unnecessary inquiries and appeals later, but their system cannot handle this now. Efforts are underway to use all of the modifiers in this way in 2003. Both PT reviewers held to a philosophy of “one passive modality per treatment” until an inquiry or appeal identifies the need for more.
2. Inconsistency in payments between PT practice settings (hospital vs private practice) for both patients and providers. Differences in reimbursement systems for hospitals and private practice settings were highlighted. Currently, most hospitals choose to not accept private practice fee schedules that govern private clinics, because their hospital reimbursement is higher, even though they may receive a large percentage write off. Again, system changes are apparently being sought, as Wellmark identified a commitment to reimburse for the “right care, at the right time, and at the lowest cost.” However, they indicate that with the dramatic changes in health care relationships and provider locations (outpatient surgery, Mobile MRI, etc.) the “target keeps moving: and systems are taxed.”
3. Three unit limit per visit. While the allowed “Initial evaluation” charge is reimbursable as a fourth unit, a commitment to the general philosophy of allowing only 3 units per service visit was reiterated as sufficient for a system with guidelines designed for meeting the needs of its members 95% of the time. However, Wellmark highlighted an opportunity for an “upfront request for an exception to the 3 unit limit.” Such a wavier was outlined as appropriate for the “train wreck” patient with multiple system problems, and with qualifying documentation as to why the patient qualifies as an “outlier.” Currently, there are no mechanisms to allow an appeal from the “back end” of a case.
4. Twenty-four visit limit. Three issues addressed included “the limit,” the best method for requesting additional visits, and the problem of EOB’s (explanation of benefits) that do not support coverage beyond the 24 visits. Even in cases where more visits are approved, the EOB statement to the patient instructs them that they are beyond their limit, and they should not pay for services, as the provider is liable for the charges. Wellmark is unable to change its computer-generated EOB’s to correct this inconsistency. However, they are educating their customer service personnel to support us with the patient questions, and to send a letter to the member to explain the EOB error, if necessary. With regard to the 24 visits, Wellmark has identified this as meeting their 95% rule, and therefore are currently committed to this limit. The problem of timely feedback after requests for additional visits was discussed. The PT reviewers and staff identified an internal goal of processing inquiries within five working days. However, consultants do not all work every day. The clarity and quality of the information provided to support inquiries and appeals could govern the speed of the process as well. Cover letters from PT’s have been noted to be critical in providing a clinical “picture” that helps convey the patient’s needs for skilled PT, as has initiating requests around the 18-20 visit timeframe.
5. Inconsistency between payments for physical therapy billed by an MD Vs PT. Reimbursement is based on coded service similar to Medicare’s Fee Schedules which identify RVU’s per code. RVU’s are converted to their reimbursement level by a conversion factor, which is higher for physician services. Currently, there are no methods to differentiate selected codes that may not be traditional MD services from the overall fee schedule, nor to take into account who provides the services for the billing provider. Some of these factors will be addressed with the November 2002 update and through ongoing mechanisms.
6. OT Coverage/credentialing. Credentialing of OT’s in private settings will begin on July 1, 2002. OT coverage will be based on a review of state statutes. All providers will get details of coverage levels in June.
7. Coverage for Temporal Mandibular Disorders. Tom identified that PT consultants are wondering to get this reviewed internally.

This reflects my best attempts to summarize our meeting. Please contact Karl K. or Bump with your ongoing questions and they will connect with Tom for the answers. Wellmark has indicated an interest to repeat this process 1-2 times per year, as they do with the Iowa PT Association. Based on the valuable information received, SDPTA requested a newsletter article and/or a presentation from Wellmark at a future meeting in order to bring this information directly to our members. Tom Reding has volunteered to be on a panel to review these issues in Rapid City in September, and a newsletter article will follow.