Payment Consortium Advocacy Campaigns

Advocacy campaigns have started to pressure United Health Care (UHC) and Elevance (Anthem) to change payment policies that cause problems for physical therapists and their patients.

Prior authorizations have become a common hurdle for patients seeking necessary treatments. While intended to manage costs and ensure appropriate care, these pre-approval requirements can significantly delay access to vital services, particularly in physical therapy. For many patients, the consequences can be detrimental, affecting both their physical health and emotional well-being.

One of the most immediate effects of prior authorization requirements is the delay in receiving care. When a patient is prescribed physical therapy, whether for post-surgical rehabilitation, chronic pain management, or recovery from an injury, timely access is crucial. Delays in obtaining authorization can lead to prolonged pain, decreased mobility, and an increased risk of complications. The waiting game that comes with prior authorizations can also take a toll on a patient's mental health. Patients often find themselves in a state of uncertainty, not knowing when they will receive approval or how long the process will take. This anxiety can exacerbate existing conditions, leading to a cycle of stress that negatively impacts both mental and physical health. In an age where mental well-being is gaining increased attention, it is crucial to recognize how bureaucratic processes can undermine patients' overall health.

Prior authorizations can also create financial burdens for patients. The process often involves multiple phone calls, faxes, and additional appointments, all of which can lead to increased out-of-pocket expenses. For those already facing financial hardship, the stress of navigating this complex system can be overwhelming. Additionally, disparities in access to care can be exacerbated by prior authorization practices, disproportionately affecting marginalized populations who may have less support or resources to navigate the health care system. Health care providers, particularly physical therapists, are also caught in this web of bureaucracy. They often spend significant time managing prior authorizations, which detracts from the time they could be spending with patients. This not only impacts the efficiency of care but can also lead to burnout among healthcare professionals, further straining the healthcare system.

In the United Health Care campaign, physical therapists are advocating for removal of the prior authorization policy that took effect September 1, 2024. For the first time, PTs in both the AOPT and the Private Practice section are joining forces to accomplish this goal under the auspices of the Payment Consortium. Physical therapists are discussing with eligible patients whether they should continue with or join an MA plan and informing patients that open enrollment for the Medicare program runs from October 15 through December 7. They are also telling their patients that UHC is the only MA plan that has a policy imposing prior authorization after the second visit and beyond. Finally, if patients want help in deciding whether to purchase an MA plan, PTs have been encouraged to share information on the local State Health Insurance Plan Assistance Program (accessible at https://www.shiphelp.org/).

Resources on the issue have also been shared. For a simple, sharable reference showing the difference between MA and traditional Medicare, PTs are posting and printing a patient resource developed by a group of rural hospitals highlighting some of the deficiencies in MA plans. It provides a comparison of traditional Medicare and the problems that can be created by Medicare Advantage plans that may be important to Medicare patients. PTs have also been encouraged to share the resource with any brokers with whom they interact as they often find themselves in a position to encourage patients to enroll in MA plans.

One of the other strategies PTs are taking to push back on the policy is the filing of an appeal (and an external review) request with the plan. Additionally, PTs have been encouraged to contact their Medicare Regional Office to register the observed impact of the policy on their patients’ health. Finally, the Payment Consortium is collecting de-identified patient stories provided by PTs across the country to use in future advocacy efforts related to the new prior authorization policy.

Physical therapists are also engaging in advocacy around the implementation in 2023 of unnecessary Anthem “time-in/time-out” requirements. Coming on the heels of a successful campaign to change a similar UHC policy, PTs are being encouraged across the country to fight back. The Anthem policies can be found here for commercial and here for Medicare Advantage; they appear to apply to commercial and Medicare Advantage plans. 

The policy requires start and stop time for each time-based code, even though practices have reported being denied payment after audits have been conducted based on their lack of time-in/time-out documentation. A list of states in which Anthem plans list includes:

1. California 
2. Colorado
3. Connecticut
4. Georgia 
5. Indiana 
6. Kentucky 
7. Maine
8. Missouri 
9. Nevada
10. New Hampshire 
11. New York 
12. Ohio 
13. Virginia 
14. Wisconsin