Robert Hall

Physical therapists are finding that private payer advocacy can have a big impact on the bottom lines of their practices, physical therapist satisfaction in their jobs, and the health of their patients. Recent wins in states across the country have been influenced by the work of the Payment Consortium, which can not directly negotiate for physical therapists, but can provide strategic information, ‘ghost writing,’ and counsel to physical therapists interested in improving their interactions with private payers.

Recently, the Payment Consortium has been consulted on or has inspired wins in Montana, Arkansas and Georgia:

  • Montana state-wide Medicaid audits repeatedly overturned on appeal. Medicaid Review, a.k.a. “Audits” began in mid-2023. MT had multidisciplinary clinics, some owned by PTs, that were asked to repay up to more than $50,000 to Medicaid for “inappropriate” code pairing and billing practices. More than half of the affected parties have had their cases heard by an independent judge, and every ruling has favored the clinic owners. Clinic owners will not be required to pay any money back to Montana Medicaid!
    What did PTs do? Appealed audit determination to independent judges after uncovering MT specifics on Medicaid audit appeals.
  • Arkansas appeals overturned. After being informed of the right to internal appeal and external review of that decision embedded in the ACA, physical therapists started appealing every denial of care from one payer. Nine out of ten were overturned by an external review. While physical therapists assumed that few if any appeals would be overturned, and the admin burden of so many appeals would be inefficient, appealing every denial led to a string of victories and access to care for patients. What did PTs do? Simply appealed denial after denial.
  • South Carolina Direct Access regulatory modification win. Physical Therapists in South Carolina previously had only been able to treat for 30 days without a referral. The South Carolina Chapter succeeded in changing language in the definition of a “referral” in applicable regulation. The result of their advocacy is that a PT may continue to treat without a referral for 30 days, but if more care is needed, all the practice has to do is give the patient a statement in writing as to the importance of seeing a medical doctor or dentist and keep a copy of the statement in their chart. What did PTs do? Sustained advocacy to change the regulatory definition of “referral” over a long period of time. 

Be sure to check out more Payment Consortium wins in our compilation available here https://docs.google.com/document/d/1DW6IoPh1ZJHHCSKzhK-2l3TiSMA31Qw6QwMk-Nu_RkQ/edit?usp=sharing and please spread the word that change is possible and also happening when practices and physical therapists engage in advocacy!