Friday, December 28, 2012

Another potential benefit of Highmark in Delaware: almost no physical therapy or chiropractic treatment

Watching the future get ready to happen to us:  Highmark is delaying [not stopping, merely delaying with what they call "soft implementation"] a new policy that would limit its customers to no more than eight physical therapy or chiropractic visits per YEAR without specific insurance company authorization.

I love the rhetoric:
“Highmark believes strongly that this program will ensure more effective care for Highmark members. Highmark wants to make certain the member is getting the right care at the right time and in the right setting.”
The reason that Highmark can do this in PA is exactly the same reason that Highmark will eventually be able to implement this in Delaware:  an artificially regulated market that prohibits competition, and is overseen by an Insurance Commissioner's Office that appears to have more interest in staying in the good graces of corporate leaders than in advocating for our citizens. But, hey, you can trust the government...


Anonymous said...

Well if you are going to be quoting Pittsburgh newspapers, you might point out that Highmark is not alone on this. Pre-authorization is a reality now. Try getting an MRI or CT scan. Anywhere. Insured by anyone. From the Post-Gazette:

Payers -- both private insurers and government ones, like Medicare -- keep a close eye on chiropractors and physical therapists, largely because of the repetitive nature of their services. Many insurers have been cracking down on chiropractors in particular since a 2005 report from the U.S. Office of Inspector General found that two-thirds of chiropractic claims filed with Medicare were "deficient" -- either because of record-keeping errors or a failure to validate the nature and duration of treatments.

Other insurers have similar policies in place, and some are more restrictive.

New York's Empire Blue Cross Blue Shield, for example, uses health-management company American Specialty Health Networks to monitor chiropractic claims. Empire requires providers to "submit clinical treatment documentation to ASH Networks for review and determination of the medical necessity of further visits" beyond the fifth visit, not the eighth.

Capital BlueCross, in Harrisburg, has been using its own case-management system for physical therapies for two years.

Bethel Park therapist Joseph Agnello, of Agnello Spine & Sports Physical Therapy, acknowledges that insurance company cost-containment policies are a "necessary evil," and that he's been in the business long enough to remember a time when therapists and chiropractors played fast and loose with billing.

Read more:

Steven H. Newton said...

I'm pleased to have attracted my own little insurance company shill/troll. Does Highmark send you specifically, or are you currying favor with your bosses by overachieving?

Here's the point about Highmark's policy and Delaware: right now I have a high-end policy through Highmark that does NOT require pre-authorization for PT for my chronically ill son. Even with that policy, Highmark tries to avoid paying for the sessions on a regular basis, despite having medical justifications from three different specialists (including the nationally recognized authority on his disease from Johns Hopkins University). Highmark demands reams of case notes from the therapist (2-3 pages each time she sees him) and still tries to bounce half the claims as not medically necessary.

When I ask what would qualify as medical necessity for the review board that Highmark uses, the answer I get is, "We'll let you know when we see it. In the meantime, send more of this, this, this, and this and we'll send it through the appeals route again."

Under BCBS of DE, which was no angel of a company to deal with, I had about 20% the issues getting services that I have with Highmark.

And the problem? As a state employee the only high-end plan that comes close to meeting my family's health needs is the Highmark plan because competition is limited by the Insurance Commissioner's office.

Highmark is not about providing excellent health care for a reasonable price via "cost containment."

Highmark is about establishing non-competitive monopolies of service and payment, and about collecting as many dollars in premiums without paying out jack as the company can get away with.

That's why Highmark has this brilliant new plan that requires you to pay NOT to see a Dermatologist.

(I notice you couldn't find anything positive to say about that one when I posted it.)

Quality care my ass.

Anonymous said...

"I'm pleased to have attracted my own little insurance company shill/troll. Does Highmark send you specifically, or are you currying favor with your bosses by overachieving?"

Your powers of perception are... a little off. To put it mildly.

I do happen to have some very strong libertarian tendencies, however, and I am surprised that someone of your ilk takes such a strong shining to the force of heroism and/or villiany in politics and culture.

We would have had manned flight without the Wright brothers. We would have gotten the steam engine without James Watt. And you'll have teledermatology whether or not Highmark comes to Delaware. How do we know this? Because teledermatology is growing in places where Highmark holds no sway. Like, you know, the University of California at Davis, which has... um... an entire department dedicated to teledermatology.

You keep bringing up these horrible things. And some of them might actually be horrible. But instead of focusing on systemic pressures, you appear to want to put a square peg in a round hole and blame it all on Highmark.

Telederm not enough for you? (Yes. It's common enough that there is even a shorthand for it. Highmark didn't invent that either.) There's tele-everything. From coughs and sniffles to high-end specialty work at the Cleveland Clinic:

Maybe this makes life worse for you. Fair enough. But even if Highmark goes out of business tomorrow and Delaware hires a bureaucrat named "I Hate Highmark" to run the insurance industry, this stuff is coming. Including pre-auths for physical therapy. I sent you a link showing that, highlighting that Highmark actually isn't even leading the charge on this, and other insurers take a much harder line. You can run Highmark out of town. Good luck. I have no skin in the game and I wouldn't care one way or another. But the odds that you'll get an insurer who, long term, is not going to crack down on physical therapy visits is absolutely zero. Zilch. There's no chance.

As for telederm, maybe that's worse for you. For a lot of people it's a huge development. Where I live, you have to drive about 2 hours to get to a dermatologist, and the appontments are about six months out. The inpatient dermatology coverage is NON-EXISTENT. Dermatology is one of the most underserved specialties in the medical field, and there are no people in the pipeline.

Yeah. I'll take telederm over no-derm.

"As a state employee the only high-end plan that comes close to meeting my family's health needs"

So there's only one plan that comes close to meeting your needs.. and that's the one you've singled out as the problem? That's one strategy, I suppose. By all means, runthem out of town. I don't work for them. In fact, they have given me reason for serious concern in the recent past. BUt.. by all means, take it to them.

You're getting telederm either way.

Anonymous said...

PS: Lest you persist in thinking that prior authorization was invented by Highmark, or that it's limited to physical therapy... here you go:

It's rationing care through inconvenience, straight up. Nobody disputes that. But it's driven not by villanous cretins in some Pittsburgh office building, but by the realities of the profoundly broken healthcare delivery system:

Medicare does it. And all the other private insurance companies do it. They will keep doing it. And it will impact more service lines moving forward. Highmark is worse than some, but not the worst by any stretch.

I am not saying that you don't have a legitimate gripe. I'm saying that your gripe isn't really with Highmark.

Anonymous said...

I would have to agree. ALL the insurances suck with their exclusions, provider lists, service limits, generic vs. formulary tables, but BC or Highmark is alot more tame in the gotcha department. Hell, I had an ultrasound done at a facility that insurance set up and sent me to. Guess what came in the mail? A bill from the MD, who read the ultrasound, because HE wasn't a participating provider! How deep is the patient supposed to go to control costs? By mere being next in a pile, I get the guy who isn't aligned? Now I'm involved in a comedy and 3rd appeal, because Highmark thinks I should have been discharged to a nursing home or skilled nursing facility, the day after coming out of ICU, because of no fever AND I only had one IV remaining. For real? A transfer to a nursing home or SNF for 36hrs. ? instead of remaining in regular hospital bed. Funny thing is, I was readmitted 10 days later for another 2 weeks from complications of that hospitalization. And they are still arguing the 36hr. overage of prior.

Unknown said...

I agree that the physical therapy and chiropractic treatment have so beneficial for the patients. These can deliver the wellness without any complexities.
physical therapy center

Anonymous said...

Highmark SUCKS!,,,,,,