(Harrisburg, PA) In an announcement today, the Pennsylvania Chiropractic Association (PCA) indicated its “strong opposition” to a new cost-management program recently introduced by Highmark, Inc., a Pennsylvania health insurer and an independent licensee of the Blue Cross Blue Shield Association.
On June 14, Highmark sent a special bulletin to health professionals introducing its Physical Medicine Management Program, which goes into effect September 1, 2012 and will be managed by Virginia-based Healthways WholeHealth Networks, Inc. Pennsylvania professionals receiving the notification included Chiropractors, Physical Therapists, Occupational Therapists, Certified Registered Nurse Practitioners and Allopathic/ Osteopathic Physicians.
The program will incorporate a care registration and authorization process for manipulation and specific physical medicine services provided to Highmark members enrolled in many Highmark plans in Pennsylvania. Under the program, a treating provider will need to obtain an authorization from Healthways prior to the ninth patient visit, essentially verifying that the visit and subsequent visits are medically necessary for the patient’s treatment and care. If the provider performs services without such an authorization, then Highmark will deny payment to the treating provider.
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Commenting on the program, PCA President John E. McCarrin, D.C. said, “We have received nothing short of a massive and consistently negative response from Pennsylvania’
PCA’s concerns are numerous, but primarily are focused on three key issues:
1. In order to receive the proper authorizations, providers must submit a treatment plan which is benchmarked against clinical algorithms for provider consideration. In addition, the patient’s case history is cross-referenced with treatment protocols for specific conditions. McCarrin said, “Health care is person-to-person and the determination of medical necessity should be between a doctor and a patient. Determinations of medical necessity under this program circumvent the importance of the treating provider’s own clinical determinations and judgments of what is best for the patient and his or her condition.”
2. PCA questions the ability and authority of an out-of-state company like Healthways to perform utilization reviews in Pennsylvania. “PCA’s experience with other such programs has been particularly troublesome. PCA has seen numerous issues arise when determinations for medical necessity are made by companies administrating a utilization review program on behalf of a Pennsylvania health insurer. This new program is truly disturbing,”
3. PCA also questions the fast implementation of a utilization review program that is not disclosed in member benefit contracts or agreements between Highmark and the providers.
McCarrin continued, “Chiropractors are always concerned about the patient’s perception when a patient’s original plan of care is altered or discontinued by insurance payers. Patients and employers who sponsor many plans often mistakenly believe that the Chiropractor is not conforming to standards required by state law and their scope of practice. Programs such as this just add to this constant misperception. The public deserves to know the truth behind what really happens in these situations.”
Dr. McCarrin concluded his remarks with a warning: “PCA will do everything in its power to prevent this program from happening. The PCA believes that this program can lead to bad consequences for patients and their treating providers. Fortunately, we have a strong Chiropractic association that will just get stronger. And our patients will not tolerate these practices.”