Physical Therapists Urge Regence to Get CareCore Under Control

They’re frustrated with the rising administrative costs and pre-authorization requirements that impose too many limits on patient visits.

Physical therapists are waiting to see if changes last week in the tier program by Regence BlueCross BlueShield, the state's largest health insurer, will relieve what they describe as an onerous administrative burden and ultimately improve the way their services are valued.

Earlier this year, Regence BlueCross BlueShield chose CareCore National, a for-profit company based in South Carolina, to administer physical therapy visits in Oregon and Washington. The company imposed a tedious preauthorization process and limitations on patient visits that irritated many in the physical therapy community; The Lund Report detailed their frustrations in an article back in March. 

The re-tiering, which went into effect Nov. 1, was based on an analysis of claims data from May 2013 through April 2014 and was planned from the start of the CareCore decision.

Chris Murphy, the president of the Oregon Physical Therapy Association, which represents more than 1,200 members, has been hearing complaints from providers about the CareCore-Regence tier structure. He sits on a four-person advisory council with Regence that meets on a quarterly basis to help resolve some of the pressing issues.

“It seems like their tiering is completely based on utilization and not based on outcomes,” Murphy said. “The idea behind healthcare reform is to increase value, not decrease use. If they're not truly measuring outcomes, then they're not getting a value equation. They're just getting a cost equation.”

Regence spokesman Jared Ishkanian said in a statement: “The tier program helps ensure that our members have access to high-quality care at an affordable cost while rewarding our most efficient providers. We first established tiers in November 2013 based on data from the previous six months. … This process includes a review process for any providers who request a tier reconsideration.”

Ishkanian did not disclose the number of providers whose tier changed.

Murphy is optimistic about the willingness of CareCore and Regence to discuss concerns raised by providers, and pointed out that earlier technical glitches in a web site and provider portal have been addressed. “We're down to the fundamental issue about value,” he said.

">Many providers who have had problems with CareCore turned to Portland attorney Diana Godwin, legal counsel for Oregon Physical Therapists in Independent Practice. She estimates that one in five of the roughly 320 physical therapists she represents in Oregon and Washington have a complaint against the company.

“It's an absolutely unmitigated mess,” Godwin said. “It's ongoing. The problems have not been solved. They solve one problem and another one pops up.”

Individual providers are even more frustrated. “My administrative costs went through the roof” with CareCore, says Keith Glasser, who owns his own practice in Portland, Optimal Results Physical Therapy. “CareCore is a way to restrict care.”

To comply with the CareCore preauthorization program, physical therapists have had to bear significantly increased administration costs for which Regence has not provided compensation, Godwin   said. The preauthorization requirements are more involved for providers in a lower tier, which can slow down patient access to care.

“This is harming patients. It's interrupting their care, particularly for a patient in acute post-surgical rehab,” she said. “Rehab is more successful the quicker you get to it, and if you have to delay you don't have as good an outcome. It's pennywise and pound foolish.”

Krystal Armstrong, who runs Astro Medical Billing in Gresham and provides billing services for five physical therapy and chiropractor practices in the Portland area, agrees that CareCore is the most difficult insurer to deal with.

“CareCore is the worst,” Armstrong said. “They're really bad. [Preauthorization] takes away from patient care.”

Godwin is working with Regence to see if it can instruct CareCore to correct problems. But that's not the only option she's pushing. “Maybe Regence doesn't renew its contract with CareCore,” she said.

Assessing the potential savings that physical therapy can provide

It's becoming increasingly difficult for private practice therapists to remain in business as administrative costs rise because of pre-authorizations required by CareCore and other insurers, as well as Medicare's multiple procedure payment reduction to outpatient therapies that went into effect in April 2013.

“Our margins are getting squeezed,” said Richard Katz, executive director of NorthWest Rehab Alliance, a network of private practicing therapists. He foresees a consolidation in the physical therapy industry that will lead to fewer independent providers.

“Payers feel that there's over-utilization of those services, which I don't think is true. I also don't think they've been able to adequately assess what savings that an investment in physical therapy can deliver.

If a payer spends $1,500 on an episode of physical therapy but it saves them a $40,000 surgery, where on the balance sheet does that savings of $40,000 show up? It doesn't, but it might be there.”

Any system, such as CareCore, that tiers providers based on past treatments is not serving the best interests of patients, Katz said.

“I would think every patient would want a provider to create a plan of care based on their acuity and needs and not have a therapist judged based on past delivery of services to patients that are potentially very dissimilar to the patient in front of them,” he said.

Chris can be reached at [email protected]

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This is impacting not only Physical Therapy, but Occupational and Speech Therapy service access as well. The article is focused on PT and orthopedic rehabilitation, but the impact to patients with neurological disorders, such as stroke and traumatic brain injury, is significant as well. With the continual disruptions and limits to treatment, progress is hard to maintain and patients and their families are left with more confusion than anything. When you are operating an interdisciplinary rehabilitation practice, the administrative burden triples. I will agree that Regence and Care Core have been receptive to input and appreciate all that particularly the OPTA and APTA have done to address the concerns that impact all rehabilitation disciplines.
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