VPTA has come to realize that some commercial payors are implementing the MPPR (multiple procedure payment reduction) esp in DC and certain part of Northern VA. Because commercial payers are privately run entities it is challenging to get them to make sweeping changes from a legislative perspective. As you know there is no federal or state legislative body that has jurisdiction over how a commercial payer mandates their policies. APTA and we suggest beginning with local advocacy efforts with the commercial payer reps if you happen to have those connections. Furthermore here are some things that can be done on an individual clinician level and
Here are some suggestions and resources that may be useful for further research.
continue due diligence with the payer
Review your contract annually. Provide outcome measures or rationale annually for why you feel that your payment should be increased.
set up a mechanism within your clinic to review the newsletters/notices/letters that come from the payer to remain informed about proposed changes. This was fwrd to the VPTA from APTA and is a notification in a newsletter in April 2018 from Carefirst about upcoming changes to billing procedures
BlueLink Provider Newsletter April 2018 Volume 20 Issue 2 Pg 10 ClaimsXten™ Implementation Update We continue the transition from our current clinical auditing tool, ClaimCheck™, to an enhanced tool, ClaimsXten across all of our claims processing platforms. ClaimsXten is a comprehensive auditing tool that allows us to manage the unique requirements of our claims processing platforms.
Clinical Edit Description Pay Percent – Therapy Professional
Recommends an adjustment in the pay percent when multiple therapy procedures are submitted on the same date on certain therapy procedures. There will be no change to the process for submitting claims to CareFirst regarding these clinical edits. Please note that you may see different outcomes for similar claims dependent upon the aligned platform. What’s Next? We will continue to keep you updated as the ClaimsXten solution is deployed on our platforms. If you have any questions, please contact Provider Service at 877-228-7268. What’s Changing? With each of the recent deployments, CareFirst’s claim adjudication is being updated. In addition to the four clinical edits announced in 2017, and six clinical edits that are being implemented this Spring, we will be implementing one additional clinical edit this summer.
Resubmit claims with an explanation
Begin filing appeals.
Review documentation standards with in their clinic to ensure that your documentation clearly reflects treatment rendered
Audits, Denials & Appeals
Nonfederal Payers That Implement MPPR
The following payers have implemented the multiple procedure payment reduction (MPPR) according to the time frames listed. As shown under the Policy heading, implementation and the extent of the reduction vary by payer.
If you are aware of any additional payers implementing the MPPR, please contact APTA at firstname.lastname@example.org.
Please feel free to contact me at email@example.com
With great appreciation and enthusiasm,
Rony Masri, PT, DPT
VPTA Practice and Payor Chair