The Value of Physical Therapy

Janet Shelley

Promote It, Don’t Discount It, and Don’t Let It Be Stolen from You

By Janet Shelley PT, DPT

The Payment Policy Committee is laser focused on providing members with tools and resources to help demonstrate the value of physical therapy, navigate contracts, and to evaluate alternative payment methodologies such as cash-based services or treating patients out of network (OON).

We want PPS members to recognize their own value, promote it to payers, and enrich their payer contracts based on that value. “Don’t Discount Your Value” has become our committee motto. We are ramping up strategies this year to address the aggressive encroachment into our profession of utilization management companies.

Our 2019–2020 work groups are organized around the daily trials private practices experience:

Emerging Issues Task Force is designed to help members stay abreast of regulations and developments that impact our daily practice. This group is working to promote inclusion of physical therapists as eligible providers via telehealth. They are following the development of new procedural codes that will describe the practice of dry needling, for example, and closely following opportunities in programs such as the Merit-Based Incentive Payment System (MIPS).

Value Driven Payment and Contracting Task Force is focused on facilitating the conversation about the worth of physical therapy. Evidence-based resources have been packaged so that an individual private practice can present a bank of data that proves the efficacy and savings associated with physical therapy when used early in an episode of care before other expensive imaging procedures or surgery. We want consumers and insurers to think “physical therapy first” for most musculoskeletal conditions. The Value-Based ToolKit will give you the confidence and swagger to use your practice’s key metrics and outcomes to negotiate payment based on the value of physical therapy and to provide examples of value-based physical therapy programs. Practices are increasingly utilizing the Model Contract Checklist to understand key language provisions in their payer contracts and push back to improve contract wording where possible.

The Cash Based/Out of Network (OON) Task Force is working to help members answer questions such as “Can I take cash from a Medicare patient?” “If I am out of network with an insurer, can I waive the patient’s copay?” “Does filing the claim as a courtesy for my patient impose any additional responsibilities to an OON provider?” “As an OON provider, do I have to respond to audit requests?” Look for the FAQs to be published soon.

The Utilization Management Strategies Task Force is tackling resources to curb the excessive management of physical therapy by third-party administrators. Arbitrary limits regardless of medical necessity and excessive administrative requests from these entities increase the administrative burden on private practice. Reduced payments to private practices (in lieu of enriching the managed entity) are leaving the patient with a reduced benefit and the insurer with a lesser outcome. While promoting our value should diminish the impact of UM vendors, PPS is looking to replicate legislative, legal, and grassroots efforts from all parts of the country that are proving successful. Our colleagues in Louisiana were successful in negotiating with their state payers to avoid a new utilization program administered through AIM Specialty Health that is sweeping across the country. A recent Cigna-ASH Settlement highlighted the unsavory practice of adding an administrative fee to pay for the utilization management services. The aggressive proliferation of these entities, the crippling administrative requirements, the lack of regulation transparency and ignoring medical necessity attestments of the licensed providers who treated the patient face to face cannot go unchecked and are stealing the value from physical therapy.

We welcome member participation on all our task forces. Please reach out to me, Janet Shelley, PT, DPT, Committee Chair, at jshelley@4mbc.com, to join us in positively changing our payment environment.


Janet Shelley

Janet Shelley, PT, DPT, is the chair of the PPS Payment Policy Committee and chief executive officer of Medical Billing Center in Greenville, South Carolina, specializing in billing for outpatient therapy. She can be reached at jshelley@4mbc.com.