“I love insurance payers!” If you were to compile a list of phrases that physical therapists are least likely to say, I’m betting that one would be somewhere near the top. And this sentiment certainly isn’t unwarranted. After all, payers—both commercial and federal—are notoriously difficult to work with.

On top of that, they often make it especially difficult for beneficiaries to access rehab therapy services. In fact, when we conducted our recent State of Rehab Therapy industry survey, we found that across all disciplines, rehab therapy professionals cited insurance requirements as the top barrier to patients accessing care on a direct access basis—and it remained the top barrier regardless of the level of direct access available in any particular state. Survey respondents also reported that government and other third-party (i.e., insurance) regulations—along with higher patient deductibles and patient financial responsibility—were the first- and second-biggest barriers to providing effective patient care.

Make Google Do It: How to Use the Internet to Win More Patients  - Regular BannerMake Google Do It: How to Use the Internet to Win More Patients  - Small Banner

Creating a Costly Conundrum

Of course, rehab therapy providers have been dealing with dwindling payer reimbursements for years, but the recent shift in patient financial burden is making it even tougher for therapy clinics to stay afloat—especially those that rely heavily on third-party reimbursements. According to the National Conference of State Legislatures, “annual premiums reached $18,764 for 2017, up 3 percent from 2015 for an average family coverage with workers on average paying $5,714 towards the cost of their coverage.” And that’s just employees with employer-based health insurance. For those purchasing private-market insurance in 2018, “the average increase with subsidies was $201.” To add insult to injury (sometimes literally), those rate hikes have largely happened without commensurate expansions in coverage—specifically for rehab therapy services. So, many plans end up discouraging patients from seeking rehab therapy care due to the high out-of-pocket cost. As a result, this makes it harder for patients with neuromusculoskeletal conditions to achieve optimal care outcomes—which ultimately leads to poorer overall health.

Finding Common Ground

With all of that said, it’s no wonder healthcare providers and consumers often point to insurance companies as the “big evil” clogging up the entire healthcare system. But here’s the great irony in that stereotype: insurance payers exist to provide beneficiaries with access to safe, quality care. (We know this because of the often arduous credentialing processes that help ensure payers contract with providers who meet their standards.) And that means ultimately, payers and providers want the same thing: to help patients achieve optimal health outcomes and avoid dangerous, costly treatment that could result in further complications down the road. And while it’s easy to dismiss this all as a cash grab on the payer end, the reality is there are a lot of complicated contributing factors to the skyrocketing cost of health care. So, here’s the real question: why aren't insurance payers making therapy services more accessible—despite the overwhelming evidence that physical therapy is both clinically effective and cost-efficient?

Hanging in Specialist Limbo

Part of the problem is the manner in which insurance payers categorize physical therapists. As WebPT’s Brooke Andrus explains in this post, “Physical therapists typically fall into the specialist category, and on the surface, that designation makes sense. After all, PTs specialize in the treatment of musculoskeletal conditions. The problem is that insurance plans often require beneficiaries to contribute higher copayments for specialized care.” Unfortunately, that problem has only gotten worse.

That’s because—in an effort to keep patient insurance premiums low—insurance companies have shifted a greater portion of the treatment cost to the patient. As a result, copays have steadily increased. As physical therapist Jill Murphy explains in this article, “In some cases, the consumer actually pays more than what the therapy provider is actually reimbursed, paying in excess of 100 percent of the cost of care.”

PTs aren’t typical specialists.

Generally speaking, patients see specialists under a very specific set of circumstances—often only a few times a year, which makes it easier for those patients to justify the financial burden of a large copay. Physical therapy patients, however, typically attend multiple sessions a week for an extended period of time, making that expenditure a lot harder to swallow. On top of that, PT is a specialty in which patients typically must pay a copay for every visit, whereas many other specialties require a single hefty copay at the start of care that covers the cost for all subsequent visits.

As Matt Hyland, PT, PhD, MPA, CSCS, points out in this article for PT in Motion, “You'd be referred to an orthopedist by your general practitioners—maybe you needed surgery or maybe you didn't—and you'd pay the higher copay. All of your follow-up visits were covered under that single copay. Well, with physical therapy they not only charge the higher copay, they also do it every single time you come in.”

Lacking Data

Of course, the other roadblock is an overall lack of data. Numerous existing studies speak to the effectiveness of physical therapy in treating everything from chronic pain to cardiovascular diseases. Furthermore, compared to traditional care routes like surgery and prescription meds, PT is a considerably more cost-effective (and safer) option for managing these conditions. So, logic would suggest that insurance payers would be hopping aboard the PT train in droves.

And yet, that’s still not happening. A big part of the reason why could be that—despite the research—the only proprietary data that payers have access to is information on service utilization and cost. In other words, there isn’t much in the way of outcomes data collection on the payer end. But, that’s not entirely for lack of trying: Medicare (along with a few commercial payers) have used functional limitation reporting as a way to collect data on the effectiveness of therapy services—and inform reimbursement changes. However, as WebPT’s Brooke Andrus reported here, CMS recently proposed to end the FLR program in 2019, as the agency “‘reviewed and analyzed the [FLR] data internally but did not find them particularly useful in considering how to reform payment for therapy services as an alternative to the therapy caps.’”

Clearly, there is still a great need for payer visibility into therapy provider outcomes, and as Heidi Jannenga, PT, DPT, ATC, WebPT’s president and co-founder, wrote here, therapists must “take matters into our own hands” by “adding the same data-tracking to-do to our individual lists.” In other words, it’s up to therapy providers to deliver the data that shows the entire healthcare world—payers and patients alike—just how valuable they are.

Taking the Next Steps

So, where do we go from here? How can rehab therapists advocate for themselves when it comes to payment reform? Are insurance companies really the enemy? After all, as I mentioned above, providers and payers appear to want the same thing. So, how can they find that common ground? To start, you, as a therapy provider or advocate, can:

  • Be part of the APTA’s efforts to limit copays (and get involved with the APTA Action Center); and
  • Call or write to the legislative powers that be and give them your perspective as someone who is actually in the trenches.

As overwhelming as advocacy seems, efforts to limit copay amounts and/or remove rehab therapists from the specialist designation have met with success in several states, including:

You can also begin tracking your own outcomes data and using it as leverage during payer contract negotiations and renegotiations. If you can present data proving the effectiveness of your care, it’ll become one of your biggest bargaining chips to obtain a better payment rates. Furthermore, these provider-level interactions represent the therapy industry’s first step toward fostering a positive partnership with insurance payers—instead of continuing to be at odds.

The fact is, insurance companies have a pretty negative rep on both the patient and provider ends. That’s certainly not without just cause. After all, they’re the ones who control the cost and reimbursement rates, right? But, there are definitely things providers can start doing right now to change payer perceptions of PT. All it takes is a little cooperation.

  • Common Questions from Our Cash-Based Physical Therapy Webinar Image

    articleAug 30, 2017 | 19 min. read

    Common Questions from Our Cash-Based Physical Therapy Webinar

    Earlier this week, WebPT’s president and co-founder, Dr. Heidi Jannenga, PT, DPT, ATC/L, teamed up with cash-based physical therapy guru Dr. Jarod Carter, PT, DPT, MTC, to host a webinar covering all things cash pay —from insurance contracting considerations and Medicare rules to self-referral marketing and service pricing. Thousands of rehab therapy professionals registered to attend, which means we received a ton of questions—so many, in fact, that there was no way we could answer all of …

  • PT Billing Tips from the Trenches Image

    articleMay 22, 2017 | 6 min. read

    PT Billing Tips from the Trenches

    It’s hard out here for a biller—between dodging denials, hunting past-due balances, and navigating the ever-changing compliance climate, keeping a rehab therapy practice’s billing processes in tip-top shape is no simple feat. The heat is definitely on when a good portion of your company’s cash flow falls squarely on your shoulders—but you don’t have to go it alone. In fact, we’ve rounded up several therapy billing gurus who were happy to lend their expertise and spill some …

  • 7 Direct Access Myths Debunked Image

    articleSep 27, 2017 | 11 min. read

    7 Direct Access Myths Debunked

    The fight for direct access to physical therapy has been raging for a while—we’re talking several decades—and as with any long-standing controversy, rumors abound. So, in the interest of removing some grist from the gossip mill, let’s tackle a handful of the biggest direct access myths out there: Myth #1: Direct access only applies to private outpatient physical therapy practices. Truth: One of the most pervasive myths in the therapy industry is that direct access only benefits …

  • The PT's Guide to Billing Image

    downloadJun 7, 2016

    The PT's Guide to Billing

    When it comes to physical therapy billing, you have to know your stuff—because even the simplest mistakes can cause denials. Of course, knowing billing backwards and forwards doesn’t have to be complicated. That’s why we created a comprehensive billing resource specifically for PTs. Take the guesswork out of billing. Enter your email address below, and we’ll send your free guide.

  • CMS Can See Clearly Now, Releases PQRS Strategic Vision Image

    articleMay 21, 2015 | 3 min. read

    CMS Can See Clearly Now, Releases PQRS Strategic Vision

    All month long, we’ve talked about the healthcare industry’s rapid evolution from the fee-for-service Stone Age to the pay-for-performance Enlightenment Period. Yes, payment reform is upon us , but don’t take our word for it—take it straight from America's largest payer of healthcare services: The Centers for Medicare and Medicaid Services (CMS). In an effort to “contribute to improved healthcare quality across the nation,” CMS recently published the Physician Quality Reporting Programs Strategic Vision , detailing a …

  • Do You Know Your PT Billing Blunders? [Quiz] Image

    articleMay 17, 2016 | 1 min. read

    Do You Know Your PT Billing Blunders? [Quiz]

    Billing for physical therapy services is tricky, time-consuming, and nerve-racking. After all, there are so many rules you have to follow, and it seems like those rules are constantly changing. That makes mistakes tough to avoid. In many cases, you might not even know you’re making mistakes. And while an occasional billing error probably isn’t a huge deal, if you’re unknowingly flubbing up left and right, you could end up in hot water. And if you’re fudging …

  • 3 Smart Ways to Use Data Reports in Your PT Practice  Image

    articleAug 8, 2018 | 8 min. read

    3 Smart Ways to Use Data Reports in Your PT Practice

    Recently, we published a blog post detailing all of the reports now available in WebPT to help Members access even greater business intelligence—which in turn helps them make important operational decisions. Today, we thought we’d cover three super-relevant business questions you can answer based on information garnered from these reports (adapted from a wonderful resource created by WebPT Product Marketing Manager Bradley LaFave and Education Team Lead Moriah Ujano). So, without further ado, here we go: 1. …

  • Bundle Up: Why Payment Bundling Could Pay Big for PTs Image

    articleApr 20, 2015 | 7 min. read

    Bundle Up: Why Payment Bundling Could Pay Big for PTs

    If you need to get into a cold swimming pool, it’s usually better—and more painless—to just dive right in. When it comes to adopting a new payment model, on the other hand, it’s usually smarter—and less risky—to take the plunge one chilling step at a time. Health care is moving toward a value-based payment environment ; there’s no question about that. But for providers who’ve been marching to the tune of fee-for-service payment since, well, forever, doing …

  • 6 Biggest Factors Impacting Your PT Clinic’s Cash Flow Image

    articleJul 23, 2018 | 8 min. read

    6 Biggest Factors Impacting Your PT Clinic’s Cash Flow

    Most of us went into physical therapy so we could make a difference in our patients’ lives. PT can be extremely fulfilling and rewarding—and for many of us, owning a practice has been a lifelong dream. Once that dream becomes a reality, however, it can be a sobering experience. Bills need to be paid and bottom lines need to be met. It’s not always easy to bring in enough money to cover cancellations and billing snafus, not …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.