Reimbursement Trends in Outpatient Therapy: Advocacy Matters!
Since 2010, outpatient therapy has experienced consistent cuts in Medicare reimbursement. While we've seen modest gains since 2020, we’re still falling short of where we stood over a decade ago.
These small wins are meaningful, but they’re not enough. When stacked against the rising costs of wages, rent, equipment, supplies and compliance, the financial gap continues to widen. In reality, we're doing more with less.
In July, CMS will release the Final Rule for 2026. With it comes a critical opportunity for change. We’re optimistic, but progress won’t happen on its own... advocacy is essential!!! Your voice matters. Let’s continue pushing for fair and sustainable reimbursement that reflects the true value of care our therapists are providing.
Things You Should Know This Week
UHC Denial Patterns Continue
UnitedHealthcare (UHC) continues to deny claims incorrectly, particularly related to authorization requirements and contract status mismatches. These denials often stem from system errors or misclassification of provider participation status, which can lead to payment delays or unwarranted denials.
Action Recommended:
Continue to monitor and audit UHC denials closely to confirm their accuracy.
If you notice recurring denial patterns that don’t align with your contract or authorization records, reach out to us, we’re happy to assist with review and appeals.
CMS Final Rule on Prior Authorizations
CMS has finalized a rule aimed at improving the prior authorization process, which includes:
Implementing electronic prior authorization (ePA) systems to streamline requests.
Requiring payers to provide faster turnaround times for prior authorization decisions.
Enhancing transparency by mandating that payers provide specific reasons for denials.
These changes are designed to reduce administrative burdens and improve patient access to necessary care. View the fact sheet here.
TRICARE West Region Waiver Extended Through June 30, 2025
The Defense Health Agency has extended the temporary waiver of outpatient referral requirements for TRICARE Prime beneficiaries in the West Region through June 30, 2025. This waiver allows TRICARE Prime enrollees to receive outpatient specialty care without prior authorization from TriWest Healthcare Alliance, provided they have a referral from their Primary Care Manager (PCM).
Key Points:
Effective Dates: Referrals issued between January 1 and June 30, 2025, are valid for services rendered through September 30, 2025.
Provider Requirements: Services must be rendered by TRICARE-authorized providers.
This extension aims to ensure uninterrupted access to necessary outpatient specialty care for TRICARE Prime enrollees in the West Region.
BCBS Federal Audit Refund Requests
Many providers are reporting that Blue Cross Blue Shield Federal Employee Program (FEP) plans have initiated refund requests tied to a recent claims audit. These refund letters are being issued for claims dating back several years and appear to be related to coding or documentation discrepancies flagged during the audit.
Key Points:
Refund amounts vary but may span multiple dates of service and patients.
Some letters provide minimal detail, making it important to request full audit findings before issuing payment.
Not all impacted providers were aware an audit had occurred prior to receiving refund demands.
Aetna Denials for Medical Records Increasing
Aetna has resumed denying claims even after medical records have been submitted, including those uploaded directly through Availity, which was previously an accepted method for resolving such denials.
What’s changed:
These claims are now being denied again despite documentation.
Practices are being required to submit a next-level appeal to contest the denial which is adding unnecessary administrative burden and delays in payment.
If your practice is seeing a rise in these denials or needs support preparing appeals, please reach out. We’re actively tracking this issue and can assist in streamlining your response process.
Things You Should Know: 2025 Updates!
1. Reduction in Medicare Conversion Factor for 2025
The Centers for Medicare & Medicaid Services (CMS) has announced a decrease in the conversion factor for 2025, dropping it to $32.3465 from $33.29 in 2024. This reduction impacts reimbursement rates for various physical therapy services.
2. Revised Multiple Procedure Payment Reduction (MPPR) Rates
CMS has updated the MPPR rates for 2025. The MPPR applies a 50% reduction to the practice expense component of certain "always therapy" services when multiple procedures are provided to a patient on the same day. The service with the highest practice expense relative value unit is paid at 100%, while subsequent services are reimbursed at 50%.
3. Increase in KX Modifier Threshold
For 2025, the KX modifier threshold has been raised to $2,410 for combined physical therapy (PT) and speech-language pathology (SLP) services, and $2,410 for occupational therapy (OT) services. The KX modifier is used to indicate that services exceeding these thresholds are medically necessary.
4. Proposed Shift to General Supervision for PTAs
CMS has approved changing the supervision requirement for physical therapist assistants (PTAs) in private practices from direct to general supervision. This means PTAs can perform services without the supervising physical therapist being physically present, potentially increasing flexibility in service delivery.
5. Telehealth Services Extension as of 3/17/25:
The ability for physical therapists, occupational therapists, and speech-language pathologists to furnish telehealth services has been extended through September 30th, 2025. This extension allows continued access to therapy services via telehealth platforms.
Things You Should Know: Addressing Authorization and Denial Issues with Optum and UnitedHealth Group
Breaking the Cycle: Addressing Authorization and Denial Issues with Optum and UnitedHealth Group
At Lincoln Reimbursement Solutions, we are dedicated to advocating for the healthcare providers we serve, ensuring they receive proper reimbursement for services rendered. However, we continue to face persistent and systemic issues with Optum and UnitedHealth Group (UHC) that are causing significant operational inefficiencies and financial strain on our clients.
The Ongoing Problem: Incorrect Authorization Guidance and Claim Denials
Our team has encountered an alarming pattern of receiving incorrect "no authorization required" messages for multiple clients. However, upon claim submission, we are met with denials stating that an authorization was, in fact, required. These denials are issued too late for retroactive authorization requests due to Optum’s strict 10-day appeal window, leaving providers in a frustrating and costly loop.
The situation is widespread, affecting all 200+ clients we service—not just a few. Beyond these incorrect denials, authorization approvals that should take 10-14 days are often exceeding that timeframe, violating Medicare compliance guidelines. Unfortunately, Optum and UHC have provided no guidance or solutions, leaving our team to navigate these issues with excessive rework and long hours on hold, often waiting 1-2 hours per call.
Escalating the Issue—Yet Receiving No Response
Despite numerous escalations to Optum’s leadership, responses have dwindled. The system inconsistencies, conflicting information, and shifting policies create an unpredictable reimbursement landscape, forcing practice owners to either appeal tirelessly or consider writing off balances—an unacceptable outcome for any healthcare business.
To further complicate matters, Optum has recently started designating long-time in-network (INN) providers as out-of-network (OON) due to what appears to be a system glitch. Even Optum's executives have acknowledged the error, attributing it to a cyber attack, but no resolution has been offered. Providers attempting to enroll in the Optum Care/Curo portal are being met with errors stating, "No organization found," despite having valid contracts in place.
A Small Victory: Reprocessing of Denied Claims
Amidst the ongoing turmoil, we have managed to push for some progress. After escalating a particularly egregious case regarding denied claims with valid authorizations, Optum has agreed to reprocess all affected claims. If you have claims that were incorrectly denied for "no authorization," do not resubmit them—Optum has committed to addressing these issues internally. We have already seen some of these claims paid out.
Additionally, for LIFE1 claims, authorization will not be required for services rendered through November 15, though the requirement will resume on November 16. However, due to ongoing portal access issues, we are currently forced to complete authorizations manually and submit them via fax—an archaic and inefficient process in 2024.
Join the Conversation
We urge our fellow practice owners and billing professionals to share their experiences. The more visibility we bring to this issue, the harder it becomes for Optum and UHC to ignore. If you have encountered similar challenges, please reach out—we are stronger together.
At Lincoln Reimbursement Solutions, we remain committed to pushing for fairness and efficiency in healthcare reimbursement. Stay tuned for further updates as we continue this fight.
Let’s hold these payers accountable—our industry depends on it.
Maximizing Reimbursement From Insurance Carriers
Some quick tips for Maximizing Reimbursement
See you at Graham Sessions 2024!
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Wishing you a season filled with warmth, comfort, and cherished moments. From all of us at Lincoln Reimbursement Solutions, we thank you for your continued support.
Looming Medicare Payment Cuts in 2024: Protect Your Revenue with Expert Billers
The Impact of Medicare Payment Cuts:
Medicare serves as a critical payer for many healthcare providers, including physicians, therapists, and other healthcare professionals. As CMS proposes to cut the conversion factor, it is essential to recognize that these reductions can lead to significant financial strain for practices. With operational costs continuing to rise and demands for quality patient care increasing, a decrease in Medicare reimbursements can make it challenging for providers to maintain their financial stability.
Strong Billers: Your First Line of Defense
To counter the impact of payment cuts, healthcare providers must prioritize their revenue cycle management. The revenue cycle involves various stages, from patient registration and billing to claims processing and reimbursement. Having a team of skilled and dedicated billers is vital to maximize revenue, especially during challenging times. Effective billers can help your practice:
Accurate Coding and Billing: Experienced billers ensure that services are coded correctly and billed appropriately, reducing the likelihood of claim denials and delayed payments.
Timely Claims Submission: Timeliness is crucial in the billing process. Expert billers submit claims promptly, reducing the time it takes to receive reimbursements.
Denial Management: Handling claim denials efficiently and timely is critical to prevent potential revenue loss. Competent billers work diligently to resolve denials and resubmit claims.
Appeals Process: If a claim is wrongly denied, a strong biller will navigate the appeals process with precision and tenacity to secure rightful payments.
Stay Informed: As healthcare regulations and billing guidelines evolve, expert billers stay up-to-date with changes and ensure compliance, avoiding potential revenue disruptions.
Empower Your Revenue Cycle with a Comprehensive Analysis:
To gain a deeper understanding of your practice's financial health, a revenue cycle analysis is a valuable tool. This comprehensive assessment evaluates your revenue cycle process from end to end, identifying strengths, weaknesses, and opportunities for improvement. A revenue cycle analysis can:
Identify Bottlenecks: Discover any inefficiencies or bottlenecks in the revenue cycle, allowing you to take corrective actions and streamline operations.
Pinpoint Revenue Leakages: Uncover areas where potential revenue leakages occur, helping you recover lost income and prevent future losses.
Optimize Coding and Billing Practices: Improve coding and billing practices to enhance claims accuracy and decrease the likelihood of denials.
Strengthen Cash Flow: Implement strategies to expedite claims processing and improve cash flow management.
Conclusion:
The looming Medicare payment cuts in 2024 present a formidable challenge for healthcare providers. To protect your practice's financial viability, it is crucial to have a team of strong, focused billers dedicated to maximizing revenue. By leveraging their expertise in accurate coding, prompt billing, denial management, and appeals processes, you can weather the storm of payment cuts.
Furthermore, a revenue cycle analysis can provide valuable insights into your practice's financial health and identify areas for enhancement. At this critical juncture, let us empower your revenue cycle and explore opportunities for improvement together. Reach out to us to discuss a revenue cycle analysis and secure the financial stability of your practice. Remember, your revenue is worth every penny, and our expertise is dedicated to protecting it.
Tips for Maximizing Reimbursement Rates
As a practice owner, maximizing your reimbursement rates for services rendered is crucial to the financial success of your practice. While it can be challenging to navigate the complex and ever-changing world of insurance reimbursement, there are steps you can take to increase your reimbursement rates. In this blog post, we'll provide tips for maximizing reimbursement rates for physical therapy services.
Verifications: Before providing therapy services, verify your patients' insurance coverage to ensure you're providing services that are covered by their insurance plan. This can help reduce the risk of denied claims and increase your reimbursement rates.
Documentation: Accurate documentation is critical to receiving proper reimbursement rates for services. Ensure that all services provided are documented accurately, with clear descriptions of the services provided, the duration of treatment, and the patient's progress. Additionally, ensure that all documentation meets the requirements set by insurance companies to avoid denied claims.
Coding: Insurance billing codes are continuously updated, and staying up-to-date on these changes can help you maximize your reimbursement rates. Consider investing in billing software that updates codes automatically, or regularly review the current codes to ensure you're using the most up-to-date codes for your billing.
Timely Filing: Submitting claims promptly can help increase your reimbursement rates. Insurance companies have strict deadlines (timely filing) for submitting claims, and submitting claims after the deadline can result in denied claims and lost revenue. Ensure that your billing staff submits claims promptly to avoid delays in reimbursement.
Denial Follow Up: Denied claims can significantly impact your reimbursement rates, so it's essential to follow up on denied claims promptly. Review the reasons for the denial and work with your billing staff to correct any errors. It's also essential to have a system in place for tracking and following up on denied claims to ensure timely resolution. Most insurance companies only give you a 30-90 days to make a correction on a denied claim.
EDI: Electronic claims submission is faster and more efficient than paper claims, and can help you maximize your reimbursement rates. Consider investing in electronic claims submission software to streamline the billing process and reduce the risk of errors. Also, ensure that almost all of your claims are enrolled to submit electronically. There are very few payors that will only accept paper claims.
Contract Negotiation: Negotiating contracts with insurance companies can help you increase your reimbursement rates. Consider negotiating for higher reimbursement rates, reduced administrative burdens, and more timely payments. It's also essential to review your contracts regularly to ensure they continue to meet your needs and goals.
In conclusion, maximizing reimbursement rates for physical therapy services requires attention to detail, accurate documentation, and staying up-to-date on changes to insurance billing codes. By following these tips, you can increase your reimbursement rates and improve the financial success of your physical therapy practice.
The Importance of Accurate Documentation for Reimbursement
Accurate documentation is essential for reimbursement for several reasons:
Insurance companies require documentation to support claims: Insurance companies require accurate documentation of the services provided to justify reimbursement. Without documentation, claims may be denied or delayed, which can impact your clinic's cash flow.
Compliance with regulations: Accurate documentation is necessary for compliance with state and federal regulations, including the Health Insurance Portability and Accountability Act (HIPAA) and Medicare requirements.
Legal liability: Inaccurate or incomplete documentation can lead to legal liabilities, such as malpractice claims.
Tips for Improving Documentation Practices:
Improving documentation practices can help ensure that your clinic is accurately capturing the services provided and supporting claims. Here are some tips for improving documentation practices in physical therapy billing:
Use standardized forms or templates: Use standardized templates to capture all the necessary information required for billing and documentation. This can help ensure consistency and completeness of documentation.
Be specific: Provide detailed descriptions of the services provided, including the type, frequency, duration, and intensity of therapy.
Document the patient's progress: Document the patient's progress regularly and clearly, including improvements or declines in function, pain levels, and other relevant information.
Timely documentation: Document therapy sessions as soon as possible after they occur to ensure accuracy and completeness.
Use electronic documentation: Electronic documentation can improve accuracy, speed, and consistency of documentation. It can also provide tools to help ensure that documentation is complete and compliant.
Regular training: Provide regular training to therapists and staff on proper documentation practices, including compliance with regulations and payer requirements.
Accurate documentation is essential for physical therapy billing. It supports reimbursement, compliance, and legal liabilities. By using standardized templates, being specific, documenting progress, timely documentation, electronic documentation, and regular training, your clinic can improve documentation practices and help ensure accurate and complete documentation. This, in turn, can improve cash flow, reduce audit risks, and improve patient care.
We'll Fight For You!
At our billing company, we take pride in our ability to navigate the complexities of medical billing and insurance claims. We are a team of experienced professionals who are committed to helping you get paid for the valuable services you provide to your patients. We understand that billing can be a headache, which is why we take care of the details so you can focus on what you do best - providing exceptional care to your patients.
We know that insurance companies can be tough to deal with, but we are ready to take them on. Our team has the expertise and knowledge to navigate the maze of insurance policies, regulations, and requirements. We will work tirelessly to ensure that your claims are processed correctly and that you are reimbursed for your services.
At our billing company, we take a proactive approach to billing. We don't wait for problems to arise - we anticipate them and address them before they become issues. We will work with you to develop a billing strategy that meets your needs and ensures that you get paid for your services in a timely and efficient manner.
We understand that every physical therapy practice is unique, which is why we take a personalized approach to billing. We will work with you to understand your practice, your patients, and your billing needs. Our goal is to provide you with the support you need to run a successful practice, so you can focus on what you do best - helping your patients recover.
In conclusion, if you're looking for a billing company that will fight for you, look no further than our team of billing ninjas. We are ready to take on your insurance and payment battles so you can focus on what you do best - providing exceptional care to your patients. Let us take care of the billing details so you can take care of your patients. Contact us today to learn more about how we can help your practice succeed!
Happy Valentine's Day!
Spreading The Love
Roses are red,
Violets are blue,
We're here to help you,
With all your billing and credentialing too!
We know insurance claims,
Can be quite a chore,
But with us by your side,
You'll stress no more.
We promise to love,
Your practice like our own,
And make sure you're paid,
For all services shown.
We know that paperwork,
Can be quite a pain,
But we're here to ease the stress,
And make sure you don't go insane.
From billing to credentialing,
And authorizations too,
We'll handle it all,
So you can do what you do.
We'll be your Valentine,
All year long,
Making sure your practice,
Is always strong!
Happy Valentine's Day,
From your friends at Lincoln Reimbursement Solutions
Maximizing Billing and Collections: Top 5 Metrics to Track
As a physical therapy practice, it's important to keep a close eye on your billing and collections processes. This can help ensure that you are getting paid for the services you provide, while also identifying areas for improvement that can lead to increased efficiency and profitability.
Here are the top 5 metrics you should be tracking for optimal billing and collections in your physical therapy practice:
Accounts Receivable: This metric tracks the amount of money that is owed to you from patients or insurance companies. Keeping a close eye on this number will help you identify any potential issues with insurance coverage, patient payments, or other factors that could impact your collections.
Denial Rates: Denial rates refer to the percentage of claims that are rejected by insurance companies. Tracking this metric can help you identify any patterns or issues with the way you are submitting claims, which can then be addressed to reduce denial rates and improve collections.
Collections Rate: This metric measures the percentage of money collected from patients or insurance companies, compared to the total amount billed. This can give you a sense of how effective your billing and collections processes are, and help you identify trends and therefore any areas for improvement.
Days in Accounts Receivable: This metric tracks the number of days it takes for you to collect payment from patients or insurance companies. By monitoring this metric, you can identify any bottlenecks in your collections process, such as long wait times for insurance approval, and take steps to reduce the time it takes to collect payment.
Average Payment Time: This metric measures the average time it takes for you to receive payment from patients or insurance companies. By tracking this number, you can identify any trends or patterns in payment times, and take steps to reduce the time it takes to get paid.
By monitoring these metrics on a regular basis, you can gain a deeper understanding of your billing and collections processes, and make data-driven decisions to improve efficiency and profitability. Whether you are looking to increase revenue, reduce costs, or simply streamline your operations, tracking these metrics can help you achieve your goals and keep your physical therapy practice thriving.
The Recipe for Success
When it comes to the success of a physical therapy clinic, one important aspect that often goes overlooked is the credentialing process for new hires. Credentialing is the process by which healthcare providers are vetted by insurance companies to ensure that they are qualified to provide services to patients. In order to ensure that your clinic is running smoothly and that your patients are receiving the best care possible, it's essential that you have a thorough and well-organized process for credentialing new hires.
Here are a few key steps to follow when credentialing new hires:
Create and utilize comprehensive new hire credentialing documents. This should include specific payor materials, CAQH information, and education and training records.
Submit credentialing payor applications to payors. This should include all of the necessary documentation and information to ensure that your new hire is approved as quickly as possible.
Have a clear process for keeping track of payor applications, submission IDs, reference numbers, etc. This will help ensure that you don't miss any important deadlines or lose track of important information.
Set follow-up guidelines for each payor. Ask the payor for their expectations and make sure that you are meeting them.
Have clear guidelines for your cosignature process or claim hold process. All team members need to be aligned on this, including scheduling, intake, verifications, therapists, and billers.
Have a process for communication with the billing team as approvals come in. This will help ensure that your billing process is running smoothly and that you are getting paid for the services that you are providing.
Have a process to recredential and reattest CAQH profiles. This will ensure that your clinic is always in compliance with the latest regulations and that your patients are receiving the best care possible.
By following these steps, you can ensure that your new hires are credentialed quickly and efficiently, and that your clinic is running smoothly. With the right processes in place, you can focus on providing the best care possible to your patients, without worrying about the administrative side of things.
Setting the Stage: Renegotiating Your Contracts
As a healthcare provider, it's important to ensure that you're being fairly compensated for the services you provide. One way to do this is by renegotiating your contracts with insurance companies to ensure that you're receiving the reimbursement you deserve. Here are some key points to keep in mind when setting the stage for renegotiating your contracts.
Review the contract, know your current rates, and compare your reimbursement to your frequently billed codes. It's important to have a clear understanding of the terms of your current contract and what you're being reimbursed for.
Know your metrics! When was your contract was executed or last negotiated? What is your current fee schedule? What is your cost to deliver care? What are your outcome scores? What special certifications or equipment do you have? Knowing these details will help you to build a strong case for why you deserve higher reimbursement rates. For example, if you a specialized service that is not widely available, this can be used to support your argument.
Write your letter of intent. Your letter of intent should clearly state your request for higher reimbursement rates and the reasons why you believe you deserve them. Be sure to include any and all relevant information outlined in number 2.
Follow up and continue to file reconsiderations if your request is denied. Don't give up!
Repeat the process and review the rate every 2 years. Negotiating your contracts is not a one-time event. It's important to review your rates every 2 years and to be prepared to renegotiate if necessary.
Remember, as a healthcare provider, you deserve fair compensation for the services you provide. Don't be afraid to fight for the reimbursement you deserve! By following these key points, you'll be well on your way to successfully renegotiating your contracts and ensuring that you're being compensated for the services you provide.
PPS 2022 - Blasting Off Into Higher Revenues!
We’re excited to see some familiar faces and meet some new ones. We look forward to seeing you all in Denver, Colorado.
Is Your Billing and Collections Process Outdated?
Don't get lost in the age of the dinosaurs. Modernize your processes and stay up to date on new billing and coding guidelines.
You handle patient care and our team will make sure you get paid!
Billing Best Practices
Below are some items you should be asking your billing team on a quarterly basis. These are your key performance indicators that directly affect your bottom line. If answers to these questions are drastically different quarter to quarter you will likely notice a difference in your cash flow.
