Ironically, the first impact to be felt is within “physical medicine”- “high touch” services provided predominantly by Doctors of Chiropractic, physical therapists and occupational therapists. If allowed to be implemented by Pennsylvania Insurance Commissioner Michael Consedine, the program will impact many patients as early as September 1, resulting in patients being denied care by a computer.
Highmark’s PMMP is also in opposition to Highmark’s own medical policies, the Chiropractic Manipulative Services and Physical Therapy Services and Procedures. These medical policies state that medical necessity (covered therapy services) ends when, “therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur.”
Attorney Charles Artz of Harrisburg-based Artz Health Law, special counsel to the PCA opined, “Medical policy gives the provider the right to conduct a real-time analysis of the patient, based upon clinical examination and evaluation and a prospectively based, reasonable expectation that the treatment proposed will cause functional progress to occur. Algorithms contradict and are inconsistent with the doctor’s right and professional obligation to establish therapeutic goals in the treatment plan.”
The PCA vehemently opposes Highmark’s PMBM program. Simply put, it is very bad medicine.
Reader’s Note: For a comprehensive summary of this issue and PCA’s intervention with Highmark, please go to PCA’s web site home page, http://www.pennchiro.org
