If you work with a physical therapist, you may have heard from them about changes coming to Premera’s payment policy around physical therapy.
It’s natural for members to have questions and concerns about the providers they depend on, and we want to clarify what is changing about our payment policy around practice expense payments and why.
What is the practice expense portion of a payment?
The practice expense portion of a medical bill is meant to cover the non-healthcare costs of a visit, such as scheduling, patient check-in, room preparation, and other overhead costs.
What is changing?
Beginning in December of this year, when therapy services are billed during a single session, Premera will allow 100% of the practice expense portion of the highest value service billed.
For each additional service, we’ll continue to allow the full amount for your therapist’s time and clinical expertise. We’ll reduce only the portion of the payment we allow for office and operating costs by 50%.
This approach recognizes that some costs apply to every service, while other costs occur only once during a visit.
The important professional work done by physical therapists will continue to be paid in at the allowed amount for every service they provide, and Premera will still pay for practice expenses for every physical therapy session – in full on the most expensive service of every session, and at 50% for the rest.
Is Premera the only health plan taking this approach to PT payments?
Not at all. This change in policy brings Premera in line with the payment policy established by the Centers for Medicaid & Medicare Services (CMS). It is the policy that determines how Medicare and Medicaid already pay for physical therapy, and one that has already been adopted by many other health plans.
Why is Premera making this change now?
As a nonprofit health plan, Premera’s duty is to do everything we can to keep healthcare accessible and affordable for the customers we work with and the members we serve. This duty has become even more important in recent years, as healthcare prices have been subject to steady increases.
Because of our nonprofit model, 90 cents out of every dollar that Premera takes in goes directly to paying providers. By adopting a policy that is aligned to much of the industry, including Medicare and Medicaid, we’re striving to keep healthcare costs from rising more for the people who ultimately pay those bills – employers and their teams.
What is not changing?
Nothing is changing about your benefits. Covered physical therapy services, the length of a visit, and the number of services billed for during a visit are all unaffected by this change. We expect these changes will not impact our members.
Does Premera expect this to impact their provider network for physical therapists?
We will be monitoring our network as always to ensure robust access to physical therapy services for all of our members. After this change goes into effect, our team will continue to monitor factors like network participation, appointment availability, and what members tell us about their experiences. We’ll use this information to speedily address any issues that may arise.
