Welcome to our new series, Ask eviCore, where we answer some of the questions submitted by providers and their office staff. I'm Mark Tate, the leader of eviCore's Provider Experience group. This month, after receiving several emails about Physical Therapy (a topic dear to my heart, as I served 6 years as a licensed Physical Therapist), we address the number of units and visits eviCore approves based on a prior authorization request. We appreciate all of your thoughtful questions, so keep them coming!
What are "waiver" visits?
Some health plans allow approval of "waiver" visits at the initial prior authorization request. Waiver visits are visits that are approved per the first request with little or no clinical information required. For example, the provider notifies eviCore that care has started for a condition, and he or she automatically receives approval for a predetermined number of visits, usually between 6 and 12. Once the waiver visits are used, the provider must submit clinical information to obtain additional visits.
Why are real-time approvals available only for the first and second request?
These early requests frequently reflect a 60- to 90-day period of care. Analysis of historical utilization management and claims information revealed that with a substantial portion of requests for therapy, the conditions resolve within this period of time and do not require more than two submissions to eviCore. Real-time approvals allow therapists to submit clinical information and proceed with treatment without waiting for an eviCore therapist to review the request.
Beginning with the third request, all requests where the therapist reports lack of progress or reports unusual findings are not eligible for a real-time approval and are sent to an eviCore therapist for review.
Why doesn't eviCore approve all the visits/units a therapist will need for an episode of care at the initial request?
Although eviCore understands that conditions may take months to resolve, visits are approved for shorter periods to ensure that the care delivered is appropriate to the patient's progress along the way. Approving visits for shorter periods allows eviCore to work with you to review the member's response to care and adjust the frequency/intensity/duration based on that response. For example, acute conditions may require frequent intervention initially. However, as the patient's condition improves, less frequent visits may adequately address his or her needs. Or, if the patient's condition limits the therapy interventions that can be used after surgery, the need for skilled therapy may be limited until the member is released to participate in an active rehabilitation program.
When visits/units are approved based on the submission of clinical information, the therapist should attempt to spread them over the approved period to prevent a gap in care. It's helpful to avoid applying historical practice patterns (e.g., three visits per week) or business models ("We always bill six units per visit.") when developing a patient's plan of care. The plan should be based on the individual needs of the patient and should evolve based on the complexity of the condition and his or her response to care.
Why does eviCore approve units (CPT codes)?
eviCore's approval of visits, visits and units, or units depends on each health plan's payment policies and management preferences. Most decisions include "visits," since a member's benefit often cites visits. Generally, if a health plan's payment policy limits the number of units a therapist can bill per visit, eviCore will only approve visits. However, if a payment policy to manage units does not exist, eviCore will manage both visits and units. The number and type of units (CPT codes) determine the cost of a visit. In cases where eviCore only approves units, it is because of state payment policies or claims system requirements.
For Physical Therapy and Occupational Therapy, CPT codes are both timed and untimed codes. The interventions (and CPT codes billed) tend to vary based on the condition, complexity, and acuity of the condition. eviCore approves units based on the clinical information provided. For Speech Therapy, two units are approved per visit. Since most Speech Therapy codes are untimed, approval of two units allows a speech language pathologist to bill two separate procedures, if medically necessary, within the same treatment visit. As in all cases, the approved visits and/or units should be spread over the approved period to prevent a gap in care.
Please continue to share your feedback, suggestions, and questions about our prior authorization process. Email firstname.lastname@example.org and Jackie Jenkins, the National Provider Advocate on my team, will reach out to you soon. We look forward to hearing from you and answering your questions in future editions of Ask eviCore.
Thank you for your continued partnership with eviCore. Together, we can ensure your patients get the test, treatment, or procedure that is right for their needs.
Master of Physical Therapy
Vice President, eviCore Provider Experience