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Wednesday, October 9, 2019   (0 Comments)
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As third-party payer pressure increases, physical therapists need to know that they are NOT powerless!


Physical Therapy (PT) is an incredibly cost-effective service that brings value to patients and payers!

·         It reduces opioid prescriptions and the potential for addiction. 

·         It reduces the need for surgery.

·         It reduces both the number and duration of healthcare services.

·         In fact, more PT often means a shorter duration of healthcare services, decreased overall expenditure and a faster return to function.


Despite the efficacy of PT, 3rd party payers are always trying to reduce or manage services in order to aggressively manage cost.  If the total cost of care- not just the PT spend- was in question… PT services would be more appropriately covered.


Because PTs are in a micromanagement mode from 3rd party payers we need to both understand the value of our services and be willing to advocate for coverage!


The NPTA has joined in advocacy efforts with multiple Chapters and the APTA to advocate for reasonable utilization management & review (UM/UR) processes for the PT services our clients need to return to their active, productive lives.  I want to outline our role in effectively navigating 3rd party payer requirements along with providing the available resources.


Please consider the following:


Contracting: When seeking to contract with 3rd Party Payers- carefully review the contract for language & requirements for participation.  Included in this review will be going out to the payer website & reviewing the Clinical Policy Coverage for Therapy Services (Including any specialties you might offer.  I.E>: Pediatrics, Lymphedema, Vestibular Rehab, etc.)  For more information on how to research 3rd Party Payer policy visits the APTA UM toolkit at


In addition, carefully review proposed fee schedules and compare them to your cost of providing services before signing!


Contract Implementation: 

Review all policies and procedures in the Provider Billing and Administration area along with the Clinical Coverage policies.


Be sure to perform necessary credentialing promptly for all providers.  Then, keep 3rd party payers updated with your locations & provider lists.


Read your contracted 3rd party payer bulletins, e-blasts and sign up to participate in all PT pertinent web-based trainings.


When receiving payments, verify that you have receive consistently against contracted rates.  Research any reductions or denials.


Utilization Management & Review (UM/UR)

Familiarize your team with the UM/UR process each payer requires and implement to the best of your ability.


If the process is inconsistently, unfairly or overzealously applied consider notifying the WPTA Payment Specialist of your specific concerns.  If the process adversely affects your ability to serve the beneficiaries/enrollees of the plan – ADVOCATE for change!



Appeal unfair denials through the Payer Appeal process (typically available on the 3rd party payer’s provider website).  Carefully research payer policy to be sure that you are following guidelines.  If you are, appeals will bring to light problems with how the policy is being applied.  Appeals that accumulate over time create a sense of concern with 3rd party payers.  Appeals filed by the patient with your assistance are often most effective.  If you can engage your patient, make sure they are also informing their employee benefits specialist of the problems they are having with the employer contracted plan. In fact, if a patient’s Human Resources Dept becomes involved that can assist in creating more urgency within the payer.


If appeals do not work and you continue to have difficulty securing appropriate coverage -consider advocating beyond the 3rd party payer.


Medicaid/Medicaid HMOs:

Work with the Medicaid Ombudsman office at

If providers have questions they should reach out to the Medicaid office at: Nevada Department of Health and Human Services- Medicaid c/o Cody Phinney Acting Administrator


1100 East William Street, Suite 101

Carson City, NV 89701

Telephone: (775) 684-3676

Fax: (775) 687-3893


Commercial Insurance:

Have your patients notify their HR/Benefits Dept regarding problems with their plan.

File a complaint through the NV Insurance Commissioner’s Complaint Process outlined:

Or contact Mark Garratt Chief Insurance Examiner at or (775) 687-0736

Both: Consider reaching out to your Legislators: Contact Susan Priestman for help with your legislator or see template letters in the APTA UM toolkit.


We must collaborate to prevent third-party payer administrative barriers to care.

Send concerns to NPTA Payment Specialist- Jenelle Lauchman at


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