TPTN PROVIDER NEWSLETTER - WINTER 2013

Transcription

1 PHYSICAL THERAPY NETWORK TPTN PROVIDER NEWSLETTER - WINTER 2013 Functional Capacity Evaluations By Cynthia G. Rega, PT, MS HSA, CEAS II Accelerated Rehabilitation Centers Inside This Issue: A Functional Capacity Evaluation (FCE) is designed to objectively measure an individual's physical and functional capabilities which provides physicians, claims adjusters, employers and case managers with an objective, valid and reliable method to determine occupational activities an individual can safely perform following a work related injury or non-occupational illness. FCE s can assist with return-to-work (RTW) and case resolution when: Contributing Article Provider Authorizations There is a question about the patient's ability to RTW There are issues of non-compliance and/or suspected sub-maximal effort The job requires medium to heavy work or repetition There has been prolonged lost time at work A provider should be chosen who understands that two FCE formats need to be offered to the claimant. The Baseline FCE and a Job Specific FCE, both take about 4-5 hours. A Baseline FCE provides information about the patient s general physical capabilities and tolerances and establishes safe guidelines for general work activity. It is indicated when the employer is offering restricted duty, there is no job to return to, or there is high probability that the worker will be unable to return to the previous job. A Job Specific FCE is used to determine an individual s ability to perform specific job activities and/or return to their previous job. For a Job Specific FCE, it is vital that the therapist obtain a job description/analysis which outlines its specific physical demands. The components of both types of FCE s include: A Musculoskeletal Evaluation A Battery of research-based Consistency of Effort testing Reliability of Pain testing Functional tolerance testing Job Specific or Generic Functional Simulation Payor Protocol Authorization Request Form 5 Member Satisfaction Survey Provider Accolades Health Awareness Updates Reminder 8

2 Page 2 CONTRIBUTING ARTICLE (cont d) Referral questions are the key to determine which type of FCE is most appropriate. Referral questions may include: Determine individual s ability to return to full duty work Determine individual s ability to return to modified duty work Determine current physical and functional capabilities Assess consistency of effort Evaluate whether worker has received appropriate rehab to date Determine need for further rehabilitation services (i.e. Work Conditioning/Hardening) When scheduling patients for an FCE referral, sources should: Provide pertinent medical records, including current medications and any past medical history (i.e. diabetes, cardiac problems, seizures, high blood pressure) Provide the evaluating clinician with the initial evaluation and the discharge notes from previous therapy bouts Inform the evaluating clinician of the referral questions and whether or not recommendations should be included in the report Provide a thorough Job Description (for Job Specific FCE s) In summary, FCE s are a powerful tool that will identify an individual s ability to safely return-to-work, provide an assessment of work tasks an individual is safely capable of performing, and uncover issues that are impacting return to work such as reliability of pain and/or consistency of effort. Cynthia has been practicing physical therapy for over 25 years, with a concentration in workers compensation over the past 25+ years. Her clinical reputation and expertise in the area of industrial rehabilitation has established her as an expert in the area. Her extensive referral base of case managers and insurance adjusters in dealing with industrial rehabilitation clients has earned Cynthia the respect of the industrial community, where she lectures on a regular basis. She has been effective in on-site programs and return-to-work outcomes at Dominicks, Hyatt, Central Grocers, and the City of Chicago Fire Dept. Cindy is a Certified Ergonomics Assessment Specialist. Far and away the best prize that life offers is the chance to work hard at work worth doing ~ Thomas Jefferson

3 Page 3 PROVIDER AUTHORIZATIONS ELIGIBILITY TPTN has an automated fax-back eligibility system you can use 24 hours a day to verify eligibility. The number to call is 888-NET-TPTN ( ). Listen for the prompts and input the requested information. Within a few minutes you will receive a fax with the eligibility information. Please do not confuse this with an authorization. You are still required to contact us to obtain prior authorization. For outpatient physical therapy services only, eligibility and benefit verification should be checked with TheraMatrix (not BCBS) on all UAW-FORD, Ford Motor Company, and General Motors UAW members with the following group numbers listed on the Medical ID card: Nationally: 87950, 87951, 87960, 87961, 87970, and Michigan only: all of the above and 87251, 87252, 87254, 87261, 87262, 87264, 87271, 87272, 87274, 87280, 87281, 87282, 87284, 87290, 87291, 87292, 87293, 87294, 87295, and Group must note General Motors UAW on upper right side of ID card AND note Traditional CARE NETWORK on lower center area of ID card. AUTHORIZATIONS As a contracted provider with TheraMatrix Physical Therapy Network, you have agreed to obtain prior authorization for outpatient physical therapy services. You can obtain initial authorization by calling and following the prompts for an initial authorization, or by faxing an Authorization Request Form to If services are approved, an authorization will be placed in our system and you will receive a fax with the number of visits authorized and the approved date range. Please keep in mind that if authorization is given for a thirty day time frame, it is only good for the number of visits approved in that time frame. In addition, if you are approved for six visits within thirty days, you must call to get the date extended if you have only used four visits in the assigned time frame. As stated above, this is a prior authorization requirement. We will not approve retrospective visits for coverage. Remember: All requests for authorization are handled in the order they are received. We have two business days to make a determination on a case. Please allow two business days to receive notification. Please call when calling to obtain authorization. Please DO NOT use the direct call back number for the UR Coordinators to obtain authorization. Please use two patient identifiers when sending a request in for authorization. For example, please supply a contract number and name. Quality is never an accident; it is always the result of intelligent effort. ~ John Ruskin ~

4 Page 4 TPTN SECONDARY PAYOR PROTOCOL FOR NON-MEDICARE PRIMARY INSURANCE PLANS Due to recent inquiries regarding TheraMatrix Physical Therapy Network s (TPTN) protocol for reimbursement of services when secondary to a Non-Medicare Primary Insurance Plan, please note our existing policy and procedure below. TPTN administers the Outpatient Physical Therapy (OPPT) benefit for specific enrollees of Ford Health Plan, General Motors Health Plan, and the United Auto Workers Retiree Medical Benefits Trust (VEBA-FORD). Eligible enrollees covered by the TPTN program are outlined by group section code in the TPTN Quick Reference Guide and Provider Manual. Each of the above mentioned health plans are self-funded and secondary reimbursement to a non-medicare primary insurance plan are only payable by TPTN when the primary payer s reimbursement has not exceeded the TPTN daily maximum cap rate for the respective state and services are prior authorized as required by our program protocols. Moreover, as the supplemental payer, TPTN will reimburse applicable co-payments and deductibles as determined by the enrollee s primary payer, not to exceed the maximum of the enrollees TPTN allowable daily cap rate per visit. In the event a primary insurance plan does not reimbursement for services and TPTN is the secondary insurer, a provider of service must meet all of the TPTN program protocols, including prior authorization and timely filing, to be eligible for reimbursement at the TPTN fee schedule. If you require additional information regarding this protocol, please contact our Customer Service Center at (888) and a dedicated representative will be available to assist you. Do not follow where the path may lead. Go instead where there is no path and leave a trail. ~ Harold R. McAlindon ~

5 Page 5 AUTHORIZATION REQUEST FORM TheraMatrix Physical Therapy Network values the relationships we have with our network Providers. We strive to improve the authorization process so that our members can access needed care within our family of quality Providers. Our new Authorization Request Form has additional information to assist us in processing authorization requests. Please remember: To fax the completed authorization request with documentation to be reviewed for medical necessity to (248) To request prior authorization within 48 hours of the member s date of service. To include documentation to be reviewed with your authorization request such as: Initial Evaluation, Re-evaluation/Plan of Care, Daily Notes, and Prescription for outpatient physical therapy. To provide your Tax Identification Number. To provide the authorization start date. We will use the date we received your authorization request if this date is not provided on the authorization form. If you have not heard anything from us after two business days of submitting the authorization request, please contact us to avoid any denials. Thank you for providing the highest quality care for our members! ~ TPTN Management and Staff "Movement is a medicine for creating change in a person's physical, emotional, and mental states." ~ Carol Welch ~

6 Page 6 MEMBER SATISFACTION SURVEY RESULTS Our latest results are in! 682 surveys were sent NATIONALLY to members treated from October December 2012, and our response rate was 41.5% Our overall satisfaction rate is 99% O v e ra ll S a tis fa c tio n 7 % 1 % 1 % 0 % 9 1 % Detail of Survey Results: Very Satisfied % Somewhat Satisfied... 7% Neutral % Somewhat Dissatisfied...1% Very Dissatisfied...0% Success will not lower its standard to us. We must raise our standard to success ~Rev. Randall R. McBride, Jr. ~

7 Page 7 PROVIDER ACCOLADES TPTN is appreciative of the efforts of our network providers to continuously render quality medical services to our membership. As evidenced by TPTN s outstanding customer satisfaction scores, you continue to meet and exceed our membership s expectations as it relates to their outpatient physical therapy. Below are a few member comments that were submitted during our most recent satisfaction initiative. This provider continues to be above and beyond my expectations when it comes to my needs. I don't know how I would be able to work without their ongoing care and dedication. I had a total hip replacement and without continued Physical Therapy, my quality of life would be difficult and painful. They have been there for me 100%. Family Physical Therapy, Flushing, MI The quality of services is excellent. Keep doing everything the way you are. Thank you. TheraMatrix Physical Therapy, Sterling Hts., MI I had a wonderful group of people who provided my therapy. Thank you! Very nice facility. Lima Memorial Hospital, Lima, OH I could not be any happier with Physical Therapy of Chesapeake Physical Therapy of Chesapeake, Chesapeake, VA My knee is much better now and I am completely satisfied with all aspects of my therapy. ProCare Physical Therapy, Crown Point, IN Carter Rehab is a wonderful, caring place to go for therapy. I would recommend them to everyone I know. Carter Rehabilitation Center, Adrian, MI The service was great as well as the location and staff Health Solutions Center, Inc., Vermilion, OH Friendly, competent, and knowledgeable. Would highly recommend Fenton Physical Therapy, Fenton, MI The staff was excellent! My recovery was quick thanks to their expertise Dwight Orthopedic Rehabilitation Center, Canton, MI The people that worked on me did a good job and I am no longer feeling any pain in the knee. Wagner s Physical Therapy, Marlette, MI I have had therapy twice with the same location. My therapist is the best!! Fitwell Physical Therapy, Inc., Flat Rock, MI My homecare therapist gave me the recommendation for the facility. This place was top draw. All of the people were very knowledgeable about the body and how to do the therapy correctly. Physical Therapy Specialists, Troy, MI I love the facility I picked and I am very happy with the outstanding care I'm receiving from all the staff. Accelerated Rehabilitation Centers, Commerce Twp., MI This was a great experience! Your staff was great, so many people working together with a smile and a great spirit!!! Thibodeau Physical Therapy, Imlay City, MI Congratulations to all TPTN providers for adhering to such high standards of patient care!

8 Page 8 HEALTH AWARENESS UPDATES Below is a calendar of health awareness events taking place thru April Use the contact listed to obtain materials to pass out at your facility. February 1-28 Heart Month March 1-2 National Sleep Awareness Week March 1-31 National Nutrition Month April 1-30 Occupational Therapy Month March 26 American Diabetes Alert Day April 1-30 National Autism Awareness Month TPTN AUTHORIZATION PHONE AND FAX HOURS Monday Thursday 8:30am 6:30pm (EST) Friday 8:30am 6:00pm (EST) Any messages left after hours will be returned within 24 hours. You may check claim status and eligibility 24 hours a day through our automated fax back process. Call and follow the prompts. You may send authorization requests 24 hours a day to the Utilization Review Department at All authorization requests will be responded to within 48 hours. Customer Service 888-NET-TPTN ( ) Authorization Request Fax TheraMatrix Physical Therapy Network 900 Auburn Avenue Pontiac, MI