Interlocking Advocacy


By Robert Hall, JD, MPAff

The Section has been working on four interlinked issues that impact the payment environment for private practice
physical therapists.

While only one may be immediately impacting your work, the other three may have outsized impacts in the near and
midterm. Each includes an opportunity for education or advocacy.


The first has shed light on a worrying trend. The implementation of AIM’s utilization review by Anthem plans has also
brought with it a new policy that disallows payment for some commonly-used CPT codes. The Section has sent out payment
alerts to its members to gauge the impact of these changes, which also include onerous administrative burdens that lead
to increased wait times on the telephone for peer to peer review. Anthem has been unreasonable in their implementation
of these changes. While they claim that the exclusions for payments are based on hard evidence, they have been silent
about their lack of infrastructure to address other payment issues. This is understandable from a vertically-integrated
company that is using its utilization management arm to limit benefits to patients that are guaranteed by Anthem. We are
working with large employer groups to also educate them about this issue, as they are not receiving the benefits Anthem
has promised them for the premium dollar employers are investing with the insurer. We have also produced materials for
your use to share with patients, state regulators and legislators, and Anthem itself. We are hopeful that in tandem with
other professional societies as well as the vigorous work of APTA, we may succeed in decreasing the impact of the
implementation of AIM’s policy and its other unnecessary administrative burdens. PPS members are simply seeking to be
paid for providing medically necessary services for their patients. Materials for advocacy for this issue are available
at ppsapta.org/practice-management/payment-resources/.


The Section also started working with a CMS contractor on a new physical therapy specific cost measure that may help
improve Medicare’s MIPS program. As the Milliman study proved, early intervention with physical therapy for the
treatment of low back pain saves costs and produces better outcomes. This information can be used in many different
payment structures, and CMS has just created an opportunity to use evidence like the Milliman study under Medicare.
As many members are aware, MIPS has been delayed and problematic in terms of its attempts to shoehorn value-based care
into the Medicare payment system. It has created administrative burdens, few winners, and vast confusion in terms of its
implementation and effect. Many members that signed up with MIPS have found that it does not pay for its implementation
because their EHRs cannot automatically capture the data necessary to succeed under the system. To date, the pot of
money available for “winners” with high MIPS scores has been divided too broadly. While this is good news for patients
because it illustrates that many physical therapists provide very high value care under the MIPS scoring system, most
practices that succeed under the current MIPS structure only succeed a little.

Enter the next wave of quality metrics. As it has rolled out various value-based payment systems as set forth in MACRA,
CMS has funded and used multiple new measures that apply to different providers of care for Medicare patients. Its most
recent round of proposed measures, “Wave 4,” includes a physical therapy-specific cost measure that will address low
back pain, or low back and neck pain. The Section has produced a comment to the initial series of questions surrounding
the implementation of the measure to try to inject the voice of private practice physical therapists in the development
of the measure. It is important that as quality is measured, administrative burden remains low or is even reversed, and
that the upsides to measurement are real for practices and patients. The exact contours of this measure have not been
decided, but the CMS contractor is open to PPS input and seems ready to produce the best cost measure possible.
Opportunities for education on this issue including a copy of the Section’s comments noting the Section’s investment in
the Milliman study on low back pain and the value of early physical therapy intervention are available
under the CMS tab.


New information blocking regulations were delayed but finally went into effect on April 5, 2021. These rules are
important to members and other physical therapists because they require that information about patients be freely, but
securely, shared. Information blocking can occur in many forms. Physical therapists have experienced information
blocking when trying to access patient records from other providers, connecting their electronic health record (EHR)
systems to local health information exchanges (HIEs), migrating from one EHR to another, and linking their EHRs with a
clinical data registry. Patients can also experience info blocking when trying to access their medical records or when
sending their records to another provider.

The information blocking regulations have changed an important HIPAA standard related to protected health information.
Before, providers like physical therapists were permitted to disclose electronic health information to certain entities.
Now, they are required to do so to avoid, even unwittingly, blocking access to that information.


As part of the proliferation of EHRs into practice, certain standards are set by the government to allow for a better
degree of standardization in how and what EHRs do. Generally, physical therapists have been frustrated by their
experiences with EHRs, which seem much less focused on patient care than billing. To improve the impact EHRs have, the
Section is working with APTA to gather data about what would be helpful information to include in Office of the National
Coordinator (ONC) certified EHRs. This standard is important because use of an ONC-certified EHR can also help generate
a higher MIPS score. But ONC standards for EHRs can be a moving target, and that flexibility is something that we hope
to exploit to make your job easier and improve patient care.

One important aspect of patient care that has been missing from EHRs that receive ONC certification is functional
status. APTA staff have proposed an elegant way to include functional status in the EHRs that you will eventually use.
Including functional status data in a patient’s EHR could be accomplished by simply adding a data element to ONC’s US
Core Data for Interoperability or USCDI,1 but advocacy is required to make sure that the data element gets adopted. PPS
experts are working to collect the information needed to persuade ONC to include the data element in the USCDI. If you
are aware of how your EHR system collects functional status, we would love to hear from you to support our arguments to
ONC that the USCDI should include a functional status data element. If you’re interested in this issue, please feel free
to reach out to us at the email address below.

All of this stuff is simple, right? The section knows that our members are swimming in a sea of administrative burdens,
billing challenges, utilization review denials, and bewildering electronic health record requirements. We are here to
help with these issues and we’re just an email away. If you have any payment advocacy needs, please feel free to contact
us at info@ppsapta.org. 


1HealthIT.gov. United States Core Data for Interoperability (USCDI).
Accessed March 5, 2021.

Robert Hall, JD, MPAff, is a senior consultant for PPS working to advocate with private payers.
He may be reached at rhall@ppsapta.org.