Ask EviCore: Navigating Therapy Prior Authorizations
Why are some therapy services either not approved or approved only with reduced numbers?
Plus, enhancements to our specialized therapy management process!
Hi, I’m Mark Tate, and my team works hard to make the provider experience with EviCore easier, faster, and more collaborative. This edition of Ask EviCore discusses enhancements that were recently made to the prior authorization process for Physical Therapy (PT) and Occupational Therapy (OT). We’ve also included some common reasons why therapy services may not be approved or approved only for a reduced number of visits. Our goal is to help our provider partners understand the process so we can better work together to ensure your patients get the medically appropriate care they need.
What changes have been made to the Specialized Therapy Management prior authorization process?
As of April, we have increased the number of visits approved for an initial PT/OT request―and these increased visits will be approved for a longer period of time. Please note this change does not apply to PT/OT requests for WellCare, Meridian, Regence, Asuris, or Bridgespan.
We know it’s important for you to be able to set expectations with your patients about the expected course and duration of their care at the start of therapy services, and we believe increasing the number of visits approved at the initial request will better enable you to do that. This also reduces the number of times your office needs to interact with EviCore, giving you more time to focus on patient care.
What are the main factors you consider in a PT/OT request?
Our primary goal is to make sure patients get the evidence-based care that fits their unique needs. To accomplish that, regardless of how many visits have been approved, providers should base the frequency and intensity of care on the patient’s condition, medical complexities, functional status, and response to care. At the same time, it’s important to avoid creating a plan of care based on historical or business practices, and instead focus on the best course of care for each individual patient. We expect providers to use only the visits (and units) that are medically necessary, and if there is a pattern of unnecessary utilization, future cases will not be eligible for expanded authorizations.
What are the most common reasons my PT/OT requests are not approved, or approved only for a reduced number of visits?
Many commercial insurance plans have benefit limits that may impact prior authorization. Health plans may also apply benefit exclusions that could impact the number of approved therapy visits. Here’s a list of other possible reasons why therapy services may not be approved by EviCore, or receive approval only for a reduced number of approved visits:
- Duplicate requests for dates of service that have already been approved.
- Duplication of services provided by another discipline (for example: OT and speech language pathology working on same goals for dysphagia or feeding aversion).
- Duplicate providers for same services.
- Services do not require the skills of a therapist (for example: routine or repetitive drills that can be completed by the patient or their caregiver).
- Request contains no clinical information, or the clinical information is incomplete.
- Patient-reported functional outcomes and/or objective measures are not included.
- Amount, frequency, intensity, and duration of services are not reasonable under accepted standards of practice.View EviCore’s clinical guidelines for Musculoskeletal Therapies.
- The patient has made limited progress over an extended length of time in therapy (prolonged treatment for chronic conditions).
- Therapy services are being provided for participation in sports/recreational activities, activities for general fitness, weight loss, and non-essential activities of daily living (i.e., driver training).
- Skilled maintenance therapy is requested when not covered by a health plan.
- The patient has achieved maximal medical improvement and is ready to progress to a home management program.
- Skilled therapy services have proven to be ineffective.
- Reasonable functional goals and expected outcomes have been achieved.
- Patient or caregiver is non-compliant.
- Therapy services are for pain mediation alone.
- Passive modalities extend beyond the acute phase of recovery.
What are some reasons why my speech therapy request was not approved, or approved only for a reduced number of visits?
Some issues specific to speech therapy that may lead to a request either not being approved or approved only for fewer visits include:
- Passive modalities extend beyond the acute phase of recovery.
- Treatment of self-correcting conditions such as developmental articulation delays.
- Educational learning services such as reading, writing, and spelling.
- Standardized testing does not demonstrate a delay.
I look forward to addressing your questions in future editions of the Ask EviCore column. Share your feedback about our prior authorization process and this newsletter with Jackie Jenkins, the National Provider Advocate on my team, at providernewsletter@evicore.com.
Thank you for working with EviCore so that together we can ensure your patients get the best possible care.