Many of you are familiar with eviCore because of Regence Blue Shields pre-authorization requirements.
The Premera pre-authorization will be a little different than what is now required by Regence.
Providers must request a medical necessity review authorization to eviCore healthcare for outpatient rehabilitation services after the initial visit. (From the Premera news Brief dated March 28, 2016)
The therapist must submit a treatment plan to eviCore healthcare for a medical necessity review AFTER the initial visit. eviCore will evaluate the plan to determine medical necessity and will respond within 2 business days. With services determined to be medically necessary, eviCore will provide an authorization/notification number and date range that will ensure prompt payment by Premera. Services that are not medically necessary will be denied. Services denied or provided without the authorization will be the liability of the contracted provider.
Some plans will be exempt. Here is a list of what we have heard so far as read in the Facebook Group: WA Massage Therapists Get in Touch (open to ALL LMP’s/LMT’s in WA State.) We will get more information on this in a few weeks.
Seattle School District-WEA (this will change Nov. 16th,2016 and WILL require after that)
Federal Premera plans-FEP
All out of state BCBS plans that bill to Premera WILL NOT require Pre-Auth
It is time to start telling the Office of the Insurance commissioner that this pre-authorization process is limiting care that is needed and time to get clients involved in understanding how this is limiting their care.
You can start by writing a letter to the OIC and sharing your frustrations. It is best to keep communications short and to the point to make the best impact. You can start with the follow letter composed by Teri Green (one of our board of directors). We suggest you make applicable changes and fill in your details and comments and sent to the OIC.
To: WA State Office of the Insurance Commissioner
Insurance Consumer Hotline at 800-562-6900 – Yes they answer their phone!
RE: Regence and Premera
Claim Delay, Cost Increase to Provider and Denying Access to Benefits
Massage Therapists are now required to go thru a third party to receive pre-authorization to treat patients. For over a year now eviCore is being contracted to provide medical necessity pre-authorization for Regence and as of July 1st we are notified that Premera has contracted with them as well.
The reason for my complaint regarding the pre-authorization for massage has three very important points.
- Claim Delay because: It already exists: Massage Therapists have always been required to have a prescription to prove medical necessity for treatment and payment reimbursement. In fact Premera has required the referring provider to include a start and end date and number of visits. Why is this not sufficient for medical necessity and massage treatment? After all it is coming from the treating physician. A doctor who has a relationship with and health history of the patient. With eviCore it is simply reviewed by an acupuncturist. Yes, an acupuncturist who is not even considered a referring provider within scope. This is a lengthy and time consuming process that delays treatment.
- Increased costs to therapists: The excess administrative work for massage therapists is not taken in to consideration for reimbursement. After receiving a prescription we are allowed to treat one session create a treatment plan. Fax it to Premera and wait two business days for authorization. We are than given 4 sessions. After 4 sessions we must reevaluate and fax request for more treatment. We may or may not, receive 2 sessions, after which we must reevaluate and fax again to possibly receive 2 more sessions. None of this new administrative work includes codes massage therapists are reimbursed for. In fact massage therapist have been reimbursed at the same rate of $60 or lower since I have been in practice since 2003. No fee review is scheduled with Premera or Regence to allow for the increase in therapists time. Furthermore, without the pre-authorization our contract states we are unable to bill the client. Thus leaving the burden on the therapist for the client to be able to access their benefits. As of this letter the Premera clients have not been notified, so explaining the change in the benefits will also be a burden left to the therapists.
- Limiting access to care: One could easily conclude that this is the insurance carrier’s way of denying access to the member’s benefits promised in their contract. Premera in fact has a plan that boasts 60 visits annually. To this day member services for many insurance companies will tell the members NO PRESCIPTION REQUIRED. Leaving the therapists to constantly battle with the members regarding the fact that we cannot diagnose and medical necessity requires a diagnosis and a prescription, and now your plan requires a pre-authorization.
I am requesting that the Insurance Commissioner’s Office look very closely at this process. Could a prescription from a referring provider be considered enough medical necessity for use of a patients benefit? At the very least create some rules regarding the practice of pre-authorization and reimbursement to the providers for the cost associated with this new process.
Letter to Clients
Please send this to your clients and post on your website and social media sites to inform your clients/patients and the public about what is going on.
We are writing to inform all Premera clients of an important change in your massage therapy benefits.
Effective July 1, 2016, Premera will begin an authorization and medical necessity review process for outpatient rehabilitation services through a company called eviCore healthcare. This means that if massage therapy is provided, the therapist must submit a treatment plan to eviCore healthcare for a medical necessity review AFTER the initial visit. eviCore will evaluate the plan to determine medical necessity and will respond within 2 business days. With services determined to be medically necessary, eviCore will provide an authorization/notification number and date range that will ensure prompt payment by Premera. Services that are not medically necessary will be denied. Services denied or provided without the authorization will be the liability of the contracted provider. We cannot and will not treat without this process.
We are currently working with eviCore for another carrier and they are very strict regarding the rules and guidelines for treatment. This letter is our effort to ensure you are fully aware of the new process.
Not all Premera plans are subject to pre-authorization, however, we were not given a comprehensive list of the included plans, so we must consider all plans at this time. We suggest that you call your carrier and ask if your plan is included in this change and ask them to explain in detail how this will affect your care. These questions can be answered by calling the number for member services on the back of your Premera insurance card.
We look forward to working with you and providing your massage care. As always, if you have any questions please do not hesitate to call our office.
Download both in Word to make appropriate changes:
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