CIGNA/Orthonet Meeting

CIGNA & ORTHONET UPDATE
 
Earlier this year, APTA had a regional conference call with CIGNA, Orthonet and representatives from APTA chapters. The following are informational points for physical therapists as it applies to these two companies.
 
According to CIGNA policies, physical therapy is rehabilitative in nature and is provided to improve or restore lost or impaired physical function resulting from illness, injury, congenital defect or surgery. The physical therapist enhances rehabilitation and recovery by clarifying a patient’s impairments and functional limitations and by identifying interventions, treatment goals and precautions. There are 3 principles that CIGNA follow in the coverage and payment of physical therapy services and they include:
o   Must be rehabilitative
o   Must document measureable progress during the course of therapy
o   Services billed must match documentation
 
In the documentation submitted by therapists, they look for periodic objective measurements of progress which must be indicated at least weekly. If the patient has plateaued then no additional visits are approved. Plateau in progress and achieving normal function are typical reasons to discharge treatment or to not authorize additional treatment. Maintenance therapy consisting of routine, long term care is not a covered benefit.
 
According to CIGNA policies, there should be a reasonable expectation that the identified goals will be met. If no improvement is documented after two weeks of treatment, an alternative treatment plan should be attempted. If no significant improvement is documented after a total of four weeks, re-evaluation by the referring provider may be indicated. If measurable improvement is made, then the progress towards identified goals should be clearly documented and the treatment plan updated accordingly.
 
From their perspective the two biggest issues when problems that they see are no documentation of progress and documentation of no progress, i.e. measures not changing over time. During the review process, the note/documentation needs to give the whole picture, not just a snapshot of what happened on a particular date of service. Therefore, during the appeal process, the therapist should submit documentation of multiples dates of service not just the date that was denied.
 
The question was asked if OrthoNet would consider extending the date of authorizations for visits. Currently, the authorization for visits has an expiration date and occasionally the date expires before the visits are used. CIGNA will not allow the therapist to continue with the remaining visits. The expiration date supersedes the number of visits remaining. OrthoNet mentioned that perhaps they could be a “little more” flexible with the dates, providing that the therapist contacts OrthoNet before the expiration date.
 
Recoupment of payments: CIGNA has contracted with Accent, a recovery service for overpayments. Accent is charged with recouping payments for services in which CIGNA paid the provider, but OrthoNet should have been responsible for payment. According to CIGNA, providers who are participating with OrthoNet must bill OrthoNet for services rendered, not CIGNA.
 
CIGNA has contacted Accent to immediately stop seeking recoupment of funds from providers so that CIGNA can assess the impact of this issue and develop another plan of action.
 
For non-participating providers, questions or inquiries should be directed to CIGNA and for those who are participating; questions or inquiries should be directed to OrthoNet. CIGNA does not delegate its customer services duties to OrthoNet; therefore customer service inquiries are handled through CIGNA.
 
 
As with any contract physical therapists should carefully review provider contracts with payers and their agents. It is also wise to have an attorney review contracts. Call VT APTA HQ if members still have questions.

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