Health Care

Blue Cross change will affect PTs, OTs

Physical and occupational therapists say a contract change being implemented by Blue Cross and Blue Shield of Kansas will cut into their revenue and could make it more difficult for patients to get timely appointments.

Blue Cross and Blue Shield is notifying providers that it plans to switch to a revised tiered reimbursement plan for therapy programs.

Beginning Jan. 1, physical and occupational therapists will be reimbursed at 85 percent of the maximum allowable payment, down from 90 percent.

Beginning Oct. 1, certified physical therapist assistants and certified occupational therapy assistants will be recognized as eligible providers, but as of Jan. 1 they will be reimbursed at 50 percent of the maximum allowable payment, also down from 90 percent.

A physical or occupational therapist evaluates a patient and sets a plan of care, but sometimes the plan is carried out by an assistant.

Mary Beth Chambers, a spokeswoman for Blue Cross and Blue Shield, said tiered reimbursements have been in place for some other providers for years. For example, she said, the reimbursement is less when a patient is seen by an advanced registered nurse practitioner than when seen by a physician.

"We're applying it now to physical medicine," she said.

"Over the past several years, we have seen a growth in our physical medicine spend that has outpaced our projections, has outpaced normal expectations, just was growing in a way that was unexpected," she said.

Given pressures from the economy and health reform, "our reimbursement philosophy for 2011 is generally to hold the line," she said. Reimbursement for most services will go up slightly, "while what we pay for other services will stay the same or go down.

"We walk a fine line in trying to keep premiums affordable for our members and offering fair reimbursement rates to our provider partners."

Diane Pickel, president of the Kansas Occupational Therapy Association, said tiered reimbursement "will be a significant decrease in revenue" for some facilities.

But the change doesn't affect only revenue, said Lynn Price, regional director of operations for NovaCare. If reimbursement is lower for assistants, more work will fall to therapists — which could increase the cost of services and lead to longer waits for appointments.

The impact could be significant in rural areas, where there are fewer physical and occupational therapists, said Cam Wilson, chairwoman of Wichita State University's physical therapy department.

Price said she understood the economic pressures on insurers. But "as a patient advocate, we're concerned regarding the services that are needed.... The question is, how well can we do this as reimbursement dwindles?"