3rd Party Reimbursement; A State Structure Perspective from …...AT Reimbursement: History In...

3RD PARTY REIMBURSEMENT: A STATE STRUCTURE PERSPECTIVE FROM

OKLAHOMADarren H. Lunow, M.Ed, ATC, LAT

OATA Past-President

Conflict of Interest/Disclosures

Advanced Orthopedics of Oklahoma

■ Sports Medicine Director/Orthopedic Clinic Care Director

– AOOK employs 9 Active AT’s■ 4 Rehabilitation Setting

■ 1 Sports Performance Setting

■ 3 Physician Extender Setting

■ 1 Administrative Setting

– AOOK is obviously interested in attaining AT Reimbursement– AOOK is NOT compensating me for this specific project

Objectives

■ Summarize past OATA efforts as they pertain to AT Reimbursement

■ Recognize critical reimbursement strategies pertaining to AT reimbursement efforts

■ Identify common arguments/counterarguments for/against AT Reimbursement

AT Reimbursement: History

■ May of 2010: Oklahoma Concussion Law

■ 2/3/14: SB1790, Concussion law update, Passed House, died in senate

■ August of 2014: OK HS Injury Surveillance Study

■ 10/14/14: Interim Study on AT’s in Youth Sports; House Public Health Committee

■ 1/12/15: HB1051, Safe Sports School Act, Passed House, Voted down on the senate floor

■ 12/15/15: SB1164, Concussion Update Bill, Signed into law 6/6/16


■ Prior to January 2016:

– Handful of AT’s– Rehabilitation Settings– Promising, but Inconsistent Reimbursement for AT Services

■ After January 2016:

– Almost an ‘across the board exclusion;’– Response:

■ “We don’t recognize athletic trainers as approved providers.”


■ Guiding Purpose: Negotiation not Legislation

■ In absence of Negotiation; Legislation can help

– 2/16: HB 2923, Passed the House Insurance Committee, Denied a floor vote– 9/21/16: Interim Study, House Public Health Committee– 1/26/17: SB825, AT Reimbursement Bill, Died in committee– 2/4/17: Sponsoring legislator resigned



– 8/3/17: OATA Meeting with Rep. Marcus McEntire, Vice-Chair, House Ins.– 9/20/17: OATA/Select Insurance Executives Meeting at the Capitol– 10/17-11/17: OATA follow up’s; No promising response from private payers– 11/17: OATA Formal application for AT provider recognition with OHCA

■ 12/12/12: Application Rejected

– 12/4/2017: OK Health Plans Association (OHPA), Regional Lobbyist Meeting– 12/17: (New) AT Reimbursement Bill Authored by Rep. McEntire



– January 24th, 2018: OHPA, Member Association Meeting■ Executives for Community Care, BCBS, Global Health, Anthem, Aetna, Cigna, United

Healthcare, & Humana

– 2/22/18; OATA follow up’s; No promising response from private payers– 3/30/18: AOOK Meeting w/Insurance Commissioner Candidate Glen Mulready

■ Extremely Promising Meeting, Negotiations set to Start with BCBS of OK

■ 11/3/18: Mulready Elected Insurance Commissioner

– 3/27/19: OATA, Rep. McEntire, Insurance Commissioner Mulready– 5/31/19: Notification of BCBS & Healthchoice AT Reimbursement Pilot Project

ARGUMENTS AND COUNTER ARGUMENTS

Arguments & Counter Arguments

■ Argument: OK doesn’t need more healthcare providers

■ Counter:

– 79.2% of all Oklahoma Counties are designated…Primary Care Health Professional Shortage Areas (Health Resources Service Administration, 2015)

– In 2004…musculoskeletal injuries…accounted for 60% of injuries of all types treated that year (The Burden of Musculoskeletal Diseases in the U.S., 3rd ed.)

– The APTA “anticipates that there will be a nationwide shortage of 18,350 PT’s by 2025” (PT InMotion News, 2016)


■ Argument: AT’s Oklahoma licensure only allows AT’s to treat athletes

■ Counter:

– “Athletic Trainer…the rendering of professional services for the prevention, emergency care, first aid and treatment of injuries incurred by an athlete by whatever methods are available, upon written protocol from a team physician or consulting physician to effect care, or rehabilitation; (OK AT Practice Act)

– “Athlete” means a person who engages in physical activity or is physically active (AT Rules Codes)


■ Argument: AT’s Oklahoma licensure does not allow for reimbursement

■ Counter:

– “Licensees shall provide services, make referrals, and seek compensation for only those services that are necessary.” (AT Rules Codes)


■ Argument: AT’s return patients to “super human” status

■ Counter:

1. Manage Inflammation2. Restore Normal, Pain-Free Range of Motion3. Restore, Normal, Pain-Free Strength4. Restore, Normal, Pain-Free Endurance5. Progressive Return to Sports-Specific Activity


■ Argument: AT’s have a Master’s Degree, PT’s have a Doctorate, and $$ is short

■ Counter:

– Active PT’s in OK: 2,193 ■ 18% hold only a bachelor’s degree

– Active PTA’s in OK: 1,585■ Associate’s degree

– 18%*(2,193) + 1,585 = 1,980 (52.5%)■ 52.5% of all reimbursable PT services are being paid to those with a associates or

undergrad degree


■ Argument: An AT’s education isn’t rigorous enough to warrant reimbursement

■ Counter:

– The BOC has been accredited by the National Commission for Certifying Agencies (NCCA) 1982.■ Other such agencies…

– NBCOT (Occupational Therapists)– AANPCP (Nurse Practitioners)– AACN (Critical Care Nurses)– NCCPA (Physician Assistants)


■ Argument: AT’s don’t have valid, evidence-based, patient outcomes measures

■ Counter:

– As Medical Director of the Kennedy Space Center… I place a high value on the contributions the KSC RehabWorks athletic trainers have made to the health and recovery of our industrial athletes. Having referred patients to these skilled clinicians over the years, I have consistently seen that their high quality of care and exceptional rehabilitative outcomes match and/or surpass that of outside clinics.” ■ Leon “Skip” Beeler, MD Medical Director, InoMedic Health Applications Kennedy

Space Center, FL


■ Argument: No one in Oklahoma reimburses for AT services

■ Counter:

– Oklahoma Worker’s Compensation Commission■ 2012 Schedule of Medical and Hospital Fees

– Covered services now include AT Services– Community Care of Oklahoma

■ Currently Credentials and Reimburses AT’s


■ Argument: Other 3rd Party Payers in other states don’t reimburse for AT services

■ Counter:

– Wisconsin (data from 2018)■ 7 Full Recognition Payers (Anthem, Unity, Physicians Plus, etc…)

■ 9 Prior Auth. Payers (Cigna, Aetna, Humana, United, etc…)

■ 36 Workers Comp Payers

– Indiana (data from 2018)■ 13 Full Recognition Payers (Anthem, Aetna, Align, Cigna, etc…)


■ Argument: CMS doesn’t recognize AT’s; Stated they aren’t qualified in 2004

■ Counter: Mixed & Inaccurate Information

– The 2004 CMS ruled against AT’s providing Physical Therapy Services– CMS has never ruled on AT’s providing AT Services – CMS “does” Recognize AT’s as Health Care Providers with NPI numbers***Necessity to eliminate “therapy services” from your vocabulary


■ Argument: Other Healthcare agencies don’t recognize AT’s

■ Counter:

– Recognized by the American Medical Association and their CPT codes– Recognized by the Health Resources Services Administration– Recognized by the Department of Health and Human Services


■ Argument: CPT Codes are written exclusively for Physical Therapists

■ Counter:

– “Current Procedural Terminology”– “For more than 5 decades, physicians and other health care professionals

have relied on CPT to communicate with colleagues, patients, hospitals and insurers about the procedures they have performed.” (AMA, CPT Website)


■ Argument: AT’s only practice in athletic settings

■ Counter:

– 2017 Oklahoma AT Membership Data■ 50% Athletic Settings

■ 27% Occupational or Other Professional Settings

■ 23% Hospital or Clinic Settings


■ Argument: AT’s aren’t in our credentialing processes

■ Counter:

– As of March 2nd, 2015, the Council for Affordable Quality Healthcare (CAQH) Proview Software includes AT’s in its verification and credentialing resources.

– More than 900 health plans, hospitals, and provider groups use CAQH■ Currently used by:

– Blue Cross Blue Shield of Oklahoma– Aetna– United HealthCare


■ Argument: Reimbursing AT’s would allow AT billing in the Secondary School Setting

■ Counter:

– The OATA has NEVER advocated for this!– The OATA has ONLY advocated for reimbursement for the AT in the outpatient,

inpatient, and hospital settings. – 3rd Party Payers must recognize the facility as well as the clinician.


■ Argument: Adding AT’s will ‘flood the market’

■ Counter:

– There are 343 actively practicing AT’s in OK (2018)– Only 79 (23%) practice in hospital or clinic settings

■ Counter: 2014 2017

– Wisconsin 20 33– Ohio 10 22– Indiana 19 63

■ Data from the NATA’s 3rd Party Reimbursement Pilot Project


■ Argument: Adding AT’s as providers will…

– Increase private payer costs■ NOPE: “No increased administrative or operating costs”

– Increase patient quantities■ NOPE: “No increased costs do to increased service utilization”

■ NOPE: “No increase in patient quantities”

– Require higher insurance premiums■ NOPE: “Did not require premium increases to any of the offered plans”

***Data retrieved from 3rd Party Payer’s in other states

CONCLUDING THOUGHTS

Concluding Thoughts

■ Support from our State’s Division I Universities– Gerald Clancy, M.D., President

■ “…I have found the licensed athletic trainer to be qualified and well-trained in providing healthcare services within their scope of practice, for which they have received a degree from our institution, a national certification, state licensure, as well as a National Provider Index (NPI) number.”

■ “Unfortunately, as the Licensed Athletic Trainer has yet to receive insurance recognition and reimbursement for their services in Oklahoma, we are preparing our next-generation of healthcare providers for a future that does not exist. In effect, we are teaching our next generation of providers to leave the state.”

■ “As the President of the University of Tulsa, I give my full support and recommendation on behalf of this effort to obtain fair reimbursement for Licensed Athletic Trainers.”

QUESTIONS?

DARREN LUNOW, OATA PAST [email protected] (918) 346-7800

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