Highmark"s PMMP Targeting Chiropractors is Postponed Again

by: DrTirpak posted: October 09, 2012

Again Highmark is delaying the full implementation of their Physical Medicine Management Program (PMMP), until January 1, 2013. Highmark's Physical Medicine Management Program was created to limit Chiropractic, physical therapy and occupational therapy visits by requiring prior authorization for any services after the 8^th treatment annually.

Highmark, an independent licensee of the Blue Cross and Blue Shield Association, claims they are extending the soft implementation based on feedback from providers needing more time to understand the program's requirements.

The Pennsylvania Chiropractic Association offers a different view. For months they have been lobbying PA State officials and Highmark to get rid of the new program. Pennsylvania Chiropractic Association President Dr. Daniel Schatzberg stated the software in flawed and unproven.

The PCA’s lobbying has had an impact. On September 28 a press releases from Pennsylvania State Rep. Camille “Bud” George, D-74 of Clearfield County, stated that he is seeking co-sponsors for a resolution urging Highmark Inc. to rescind its use of the Physical Medicine Management Program.

He feels this unfairly hurts patients who have a legitimate need to see a physical or occupational therapist or chiropractor. Rep George said, “Let’s use a little common sense: Who is better to make that determination, a physician or a computer program?”

The Pennsylvania Chiropractic Association also met with the Pennsylvania State Insurance Department Commissioner Michael Consedine. Unfortunately that agency is not capable of stopping the implementation of the program because they lack the authority and the limitations of the current laws.

For more information on the PMMP visit the Pennsylvania Chiropractic Association 

Donate to the Pennsylvania Chiropractic Association’s Legal Fund

Prior Stories: Highmark Slowing the Implementation of PMMP for Chiropractors

Highmark Will Require Prior Authorization for Chiropractic

Highmark Slowing the Implementation of PMMP for Chiropractors

by: DrTirpak posted: August 30, 2012

On Aug 29th 2012 days before the Physical Medicine Management Program (PMMP) was set to start Highmark sent out a press release stating they decided to institute a “soft implementation”. They went on to explain that the PMMP, which is intended to limit chiropractic and physical therapy visits, would not issues any denials based on medical necessity or appropriateness with dates of service prior to Oct. 1, 2012.

The Pennsylvania Chiropractic Association since the first remarks from Highmark about PMMP has been mouting an attack on the behalf of chiropractors against this attempt at limitng a patient's use of benefits. Two weeks ago the Pennsylvania Chiropractic Association’s Board of Directors authorized an aggressive fund-raising campaign to stop the Highmark Physical Medicine Management Program, jokingly known as ‘pimp’. As of today they have raised $58,400 with the goal of $150,000. Discussing the PCA Legal Fund PCA President Dr. Schatzberg stated, “Our practices and those of the future will be irrevocably changed if this policy (Highmark’s PMMP) is allowed to be implemented. Let’s be clear: this is not our final battle; in fact, our fight is just beginning.”

The PMMP system requires chiropractors and physical therapists to submit prior authorizations through Highmark's NaviNet after 8 visits. According to the press release providers are still expected to submit requests for authorizations for treatment for September of 2012 and Highmark reserves the right to review any of those payments after they have been received.

Donate to the Pennsylvania Chiropractic Association’s Legal Fund

Prior Story: Highmark Will Require Prior Authorization for Chiropractic

Highmark Will Require Prior Authorization for Chiropractic

by: DrTirpak posted: June 21, 2012

Health insurer Highmark Inc. will require prior authorization for chiropractor services starting September 1^st in Pennsylvania and West Virginia. Pre-authorization will be required only after the eighth visit for a particular types of services in a calendar year. The policy applies to all Highmark members insured through employer-based group, as well as individual members and Medicare Advantage members.

Chiropractors know from other insurers that this is just an arbitrary cutoff, created to limit costs and create more hoops for DC’s to jump through to get reimbursed. The real losers are patients that pay for health insurance only to have their coverage limited, not based on their needs but insurance companies’ cost cutting measures.

The company set the new threshold for therapy and chiropractic visits at eight because Highmark's data show that "nearly two-thirds of members have their needs met and resolved within eight visits," according to a June 19th press release from the company.

They also claimed “data for some practices during the past two years shows chiropractic care is the second highest paid service for members, second only to cardiac care. The company spent about $200 million in 2010 on chiropractic, occupational therapy and physical therapy payment -- $100 million for chiropractic-related services, and almost $100 million more in occupational and physical therapy reimbursement. “

The outgoing president of the Pennsylvania Chiropractic Association, John Carrin DC stated."They're going to be eliminating care for patients who may need it, [based] on computer algorithms,"

Highmark Inc., based in Pittsburgh, is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Highmark serves 4.9 million members in Pennsylvania and West Virginia.