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PRESIDENTS COLUMN
CARRIE ABRAHAM PT, DPT, MPH
CONTENT PRESIDENT, WVPTA
Presidents Column Happy Physical Therapy Month! It is a very busy Fall for many people
out there! Thank you all for what you do to provide the citizens of WV
From the Desk of Dr. with quality physical therapy care. I want to give a special shout out to
Eric Tarr our volunteer warriors who have been so willing to generously serve the
profession of physical therapy in WV by their presence on our board of
Education Committee directors and their work in our committees. I wont share anyones age,
Update but some have been in this for the long haul! And, in the process of
serving, they have provided much needed guidance, wisdom and insight
Insurance Updates to many young professionals and emerging leaders. Thank you!
INSURANCE UPDATES
SALLY OXLEY, PT, OCS, CHT, CMDT
WVPTA Payer Relations Committee Chair
Workers Compensation Call with the Insurance Commission, October 24th. Carrie Abraham , Cindy
Skiles, Jeff Stevens, Johnna Gaunch and I had a conversation with Tonya Gillespie, CPA, Assistant
Commissioner of the OIC and Andrew Pauley, CPCU, Deputy Commissioner and General Counsel of the WV
OIC. The conversation resulted from a complaint that was filed with the Insurance Commission against One
Call Medical and its subsidiary Align Networks, a Workers Compensation network. It was very educational,
but the information was not what we had hoped to hear. The Insurance Commission only has jurisdiction over
licensed insurance plans, not networks.
When a Workers Compensation carriers get a managed care plan accepted by the Insurance Commission
networks get involved. The companies are exempt from the state fee schedule and the employees lose the
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right to choose their providers except in the instance of a second opinion or if they are willing to share in the
cost of care.
The OIC does not have jurisdiction over self-insured (ERISA) plans. The Department of Labor does. They do
not have jurisdiction over federal (Medicare) or state programs such as Medicaid and PEIA. They do not
regulate networks/silent PPOs.
If providers have a complaint to file with the OIC the person to send it to is Dena Wildman, Director of
Consumer Services. If they do not have jurisdiction they will try to assist by sending it on to the proper agency
or department. The take home message is be very careful signing a contract with an insurance company and
especially the discount networks. Be sure it pays enough to cover your expenses and if you do not understand it
get an attorney to read it over and explain it to you. Watch your EOBs carefully to be sure you are getting the
reimbursement that you signed up for. Signing a deeply discounted contract undervalues the physical
therapy profession.
Highmark It is necessary that all practices update their practice information with Highmark, such as:
the provider name is correct
the practice name is correct
the providers specialties are accurately listed
there are not providers listed at practice locations where they dont actually practice
the providers address and phone number are accurate
the provider is accepting new patients.
If this is not done the providers may be removed from the directory and their status within
Highmarks networks may be impacted. Detailed instructions are available in the Provider File
Management Navinet Guide, which is available on the Provider Resource Center under
Education/Manuals.
Medicare CMS will be releasing the Physician Fee Schedule on November1, 2017. A 2% increase is
projected.
Medicare will not be adding any new Bundle Total Joint Programs. Current plans are to reduce the
number of mandatory areas from 67 to 34.
Medicare plans to introduce MIPS (Merit Based Incentive Payment System) for Physical Therapists.
PTs will be told in May if they will be implementing it in 2019. 2019 will report on 2017 data. It is
possible to get increases or reductions of 3%, 5%, 7%, or 9% based on data submitted.
Humana Update on Humana audits. Humana is continuing to do audits all over the country. Be sure to
send in all the information they ask for within their timeline to avoid funds being recouped. We have not heard
of many recoupments so far in those providers that send in requested information.
Humana is starting a Total Joint Replacement Episode-based Bundled Payment Initiative nationwide. It is not
clear when it will begin and there is no information on the website regarding how it will affect physical therapy
providers.
Medicaid Providers were notified in August by Aetna Better Health of WV that due to an incorrect fee
schedule being received and loaded, claims related to RVRBS were incorrectly priced and there will be
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upcoming adjustments on future remits. The corrected fee schedule has been loaded and claims are now pricing
accurately. This appeared on their website. Providers received a reduction in the fee schedule and money has
been taken back, in some cases thousands of dollars on claims from January, 2017 through August. Taking
back money on subsequent remits causes an accounting nightmare trying to keep up with the accuracy of the
process. We asked if we could refund the money instead which would help our bookkeeping and were told,
NO.
State Policy and Payer Forum I attended the forum in Detroit September 16th and 17th. There were
several take home messages:
TREASURER UPDATE
MATTHEW MADRID, MSPT
WVPTA Treasurer
No Current Issues or Concerns Raised from executive committee meetings and/or chapter members.
Peer Review Audit - 2016 WVPTA peer review audit completed by President, Executive Director, and
Treasurer. Review forwarded to Margo Westenhoff, staff accountant at APTA.
Morgan Stanley Investment Account Transition to Vanguard Based upon email and phone
communication between Mike Bostler, APTA independent investment advisor and WVPTA executive
board members. Completing Vanguard Brokerage Account application for organizations. Once
completed and application accepted, treasurer will contact Morgan Stanley to terminate account and
liquidate assets.