Are You a Patient with Anthem Blue Cross?

Do you use Anthem Blue Cross as your primary health insurance company? Have you received this letter in the mail?

Confused? Angry? You should be! Essentially, the people you pay so you can have access to medical care are telling you they’re going to start limiting your access to medical care. By hiring a third-party to decide if your physical therapy treatment is “medically necessary” (a legal term, not a medical one), Anthem Blue Cross (BC) is opening up new channels for being able to avoid paying for your medical care.

At Rausch Physical Therapy, we work hard to provide exceptional, quality care that is easily and affordably accessible, and it’s troubling that this practice of limiting your access to medical care has become the norm for medical care insurance companies.

 

How Rausch PT currently handles insurance companies/payment

Regardless of what that letter above implies, since the passage of the Direct Access bill in 2014 Californians have not needed a doctor’s referral/prescription before coming into a physical therapy clinic for treatment. You can come to Rausch Physical Therapy at any time for any injuries or impairments that prohibit your mobility, function, and/or quality of life. The issues only arise when it comes to figuring out who pays for this treatment.

Ever since it opened in 2006, Rausch PT has been on the leading edge of forward-thinking healthcare, and Direct Access made possible what owner Kevin Rausch had always envisioned: all people having an easy entry point onto the road to rehabilitation and recovery.

Currently, once our patients come in our door they have two options to pay for their medical treatment:

1. Pay an out-of-pocket cash rate
2. Have their insurance help cover the cost of their visit; once we submit their claim to and receive approval from their insurance company, the patient is only responsible for their copayment or deductible.

Whichever payment option you choose, everyone from our front office staff to your physical therapist to our billing department is dedicated to providing you with the best experience and highest quality of care possible.

How the introduction of OrthoNet affects you

Following the lead of other large health insurance companies, BC has decided to bring in a third-party management company, in this case OrthoNet, to handle the authorization of its physical therapy treatment claims. It’s OrthoNet’s job to scrutinize every claim request we submit on behalf of a patient to determine if said visit is—by OrthoNet’s definition—”medically necessary.” After we submit your claim, OrthoNet has two business days to gather all the necessary “clinical information” and either approve or deny your request. If they do approve your claim, OrthoNet will then tell you exactly how many visits it should take you to get better in and subsequently will only pay for.

Please note that this change does not affect BlueCard or Blue Cross Blue Shield members.

Why is this troublesome?

Let’s use the curious cases of Jenny and John as examples to illustrate the potential pitfalls of this increasingly-popular decision by medical care insurance companies to hire third parties to manage their physical therapy claims.

Jenny’s Case

What happens if your claim is denied?

[toggle title=”Click to read…”]Jenny loves to run, but she pushed herself a little too hard this triathlon season and now has knee pain that’s started to limit her ability to train. As an Anthem Blue Cross member, Jenny decides to take advantage of those 60 physical therapy visits she’s allotted per year and immediately makes an appointment at Rausch PT. During Jenny’s first appointment, the front desk sends a request to OrthoNet to get approval for payment for Jenny’s appointment. Jenny sees her PT, and after his initial, hands-on evaluation, he believes Jenny will be back to running pain-free after four or five visits.

Meanwhile, someone at OrthoNet is reviewing Jenny’s case and decides physical therapy treatment for her chronic knee injury is not medically necessary. She does not need surgery (yet) so they deny paying for treatment. They cover the cost of the initial visit, but Jenny now must decide if she’s going to pay cash rate to continue with her compelling treatment plan that will allow her to continue doing what she loves.[/toggle]

John’s Case

What happens if your claim is approved?

[toggle title=”Click to read…”]John is a senior in high school and has sprained his ankle playing basketball. John’s mom received the letter above, and per Anthem Blue Cross’ suggestion she makes an appointment for John to see an in-network doctor. Two days and $150 later, John comes in to Rausch PT with doctor’s approval in hand, ready to start getting better.

On his first visit, we send a request to OrthoNet to get approval for payment for John’s appointment. John sees his PT, and after her initial, hands-on evaluation, she tells John he should be 100% after four or five visits and back on the court before playoffs start in two months.

Meanwhile, someone at OrthoNet is reviewing John’s claim, and two days later they send a payment approval notification. However, OrthoNet has determined that John’s sprain isn’t that bad, so he should be able to start feeling better after a couple visits. ABC will only help pay for two appointments to treat his ankle.

John and his PT work hard in those two visits, but he’s still only at about 60%. Inevitably, John is put in a difficult position: does he continue treatment by paying out of pocket so he can make it back in time for playoffs, or does he stop treatment and retire his jersey—or worse yet, try to play anyways and potentially cause lasting damage?[/toggle]

The takeaway

It’s unfortunate that even if your physical therapist—or even your doctor—understands your treatment as medically necessary, an outside company can still refuse to acknowledge it as so and require you pay for treatment on your own (on top of you still paying for health insurance.) It’s even more frustrating to us as a provider that we can be limited in the amount of treatment we can give people who come to us for help.

Our patients have and always will be top priority at Rausch Physical Therapy; our sole concern is getting you feeling better so you can get back to doing what you love. Our team of licensed physical therapists spent many years in school to receive their bachelor, master and doctorate degrees and licenses so they could diagnoses and relieve chronic pain and heal injuries to give someone a better quality of life. We don’t believe you should have to live with pain for any reason, especially if that reason is because an outside management company says treatment for your pain isn’t “medically necessary.”

What Rausch Physical Therapy is doing to help

1. During the last week of October, our front desk staff will be contacting our Anthem Blue Cross patients who are already scheduled for treatment on or after November 1. Together, we’ll work to complete the additional paperwork required to request “prior authorization” so we can continue providing you with quality treatment through the end of the year.  Again, this change is effective November 1, 2015.
2. At Rausch Physical Therapy, we believe that everyone should have easy, direct access to PT, a physical medicine and rehabilitation specialty that we see change lives every single day. To prepare for the potential influx of BC claim denials after November 1, we are currently working on rolling out new, innovative ways to give you, our valued patient, more payment options so you will never have to rely on referrals or allow your health insurance company to limit your health.

 

What can you, the patient, do to help?

1. Raise a ruckus! Be proactive. Demand access to the care you pay for and deserve. Call the Anthem Blue Cross customer service number. Then email your friends, get on Facebook, Tweet, and share this.
2. If your claim is denied for being “medically unnecessary… Fight back and appeal. According to the U.S. Government Accountability Office, you have a 50-50 chance of getting your appeal approved if it’s an issue of medical necessity. It may take a little longer, but if the amount of money is significant or the issue important enough to you, it is worth the time you take to make it right. Get the forms you need and fill them out and send them off. Rausch PT and/or your doctor can help by providing additional medical information to the request to show exactly why it is medically necessary. Don’t be intimidated by your insurance company; we’re here to help. Click here for the forms you need to file a complaint.

If you have any questions, please feel free to call our office at (949) 276-5401 and we’ll be happy to answer any concerns you may have to make this transition as easy as possible.

When was the last time you rolled up on race day feeling 100% prepared? Think back to your last big race, were you healthy, well-rested and happy with your training? There are so many factors to getting race ready; it takes a lot of planning to get it right, but it is possible.

Unfortunately, I normally work with athletes who don’t get it right. They end up hurt, bummed and sulking into our physical therapy office. The funny thing is, all I usually hear during that first appointment is, “I know better,” or  “Yeah, I felt this pain starting a couple months ago, but…”

Enough with the buts! Here are five easy steps to follow to make sure you get it right for your next big race. These steps work for any kind of race—running, cycling, triathlon, ultra or IRONMAN.

Step 1: Start training sooner.

Don’t rush into a long distance race without giving your body enough time to train to adapt. Your body is amazing and it will adapt to what you ask it to do; you just have to give it the right amount of stimulus and time. It’s pure physiology from there. Tough workouts break down muscle fibers and cause micro-inflammation in your tissues; the recovery time in between workouts allows your body to heal and subsequently get stronger each week.

However, this could be a lot to ask of your body if you decided to just go hard every day for a month in anticipation for a big race. That’s where the magical taper time comes in (See Step 5.)

Step 2: Pilates & Yoga count during your training.

Don’t skip core and flexibility training—those two are the keys to injury prevention.

Step 3: Love your tissues.

Stretch every night, use the foam roller and/or massage stick, and make regular appointments to get worked on by a manual physical therapist or therapeutic massage therapist.

Step 4: Recover.

In between every work out, use recovery tights, Norma-tech, Compex, hydrate, and eat like an athlete.

Step 5: STOP! Taper Time.

Plan for a “tapering period” and build it into your training schedule. Tapering periods can be one week for short races and up to three weeks for longer races. Start to taper by decreasing the distances/time of your workouts, then use that saved time for MORE TISSUE WORK (See Step 3.) At minimum, get one massage during your taper period, but a couple would be better!

Benefits of training tapering

By scheduling in a tapering period toward the end of your training block, you give your body the final healing and prep time it needs before a race. However, this can only occur if you take advantage of the “extra” time you have because your training volume is lower. If you get massage work done, stretch, and use strategies to benefit from this tapering period, then your body will do its final recovery from all your months training.

Finding out how much taper time your body needs is a balancing act that you’ll get better at every year. Working with an intuitive coach can help, but remember that you are the only one your body talks to, so it’s up to you to listen to what your body is trying to tell you and act accordingly.

FINAL STEP: Enjoy the heck out of your race!

Once you get into the groove of well-planned training, core work, tissue work, recovery, and tapering, you’ll realize how much easier it is to be a successful racer.

All the best to your health,

 

 

 

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As the president and founder of Rausch Physical Therapy & Sports Performance, Kevin Rausch, PT, MPT takes great pride in the care of every single patient he treats. Kevin specializes in sacroiliac joint dysfunctions, running and cycling injuries, and return-to-sport planning for athletes. Since the first day he opened his clinic in 2006, Kevin has strived to provide the best in care, service and technology so as to strengthen his patients’ total body health and get them back to doing what they love.

Find Kevin on Google+

 

You’ve seen it on professional athletes, you’ve seen it on weekend warriors, and if you’ve been to our clinic you have definitely seen it on our patients. So what exactly is that colorful, stretchy tape, and should YOU be using it, too?

Go into any sporting goods store and you’ll immediately notice that there are many different brands of kinesiology tapes out there (each claiming to be better than the other,) but what exactly separates the different brands? More importantly, how do you know which one will help best with your own recovery? To answer these questions, you first have to understand what k-tape is and how it works.

What is kinesiology tape?

The basic idea behind all kinesiology tapes is that they are elastic, which means that they stretch and move with you. This is in contrast to your average white athletic tape, which is more rigid and hence limits mobility. Most kinesiology tapes have a heat-activated adhesive component, which allows the tape to last a few days on clean skin without peeling off (even after showering!) Some brands offer cotton-based tapes with natural dyes, while others have more of a nylon component with artificial coloring. Some tapes come pre-cut, while others are sold in roll form. If applied properly, they all essentially do the same thing.

How does kinesiology tape work?

The most common ways to tape muscles or joints using kinesiology tape is to ask yourself why you are taping in the first place: are you taping to inhibit (relax/shut down)? Facilitate (activate)? Stabilize, control edema/swelling, or control pain? Each of these techniques requires specific placement and different tension application in order to perform their duty. While you can certainly YouTube “K-Tape,” “Rocktape,” “Kinesiotape,” etc. and find millions of videos on how to fix that pesky ITB issue or stabilize a knee cap that won’t stop moving, it’s best to have a professional teach you the specifics and application technique to receive optimal care and avoid the potential for other injuries.

You’ll probably notice that most brands have a swirl pattern of adhesive on the backside of the tape. Not only are they cool to look at, those swirly lines also serve a purpose. The swirls expand and recoil based on the amount of stretch a practitioner applies to the tape, targeting small receptors within the skin and underlying tissues to assist with healing. The amount of tension applied, the area of skin covered, and the directionality of how the tape is applied are all key factors in getting the best results.

Kinesiology tape DON’Ts Now, some of the following may seem silly to some and have you saying, “Duh!” Nevertheless, I have to caution you on the following issues you can run into with kinesiology tape, as I wouldn’t bring them up if they haven’t happened to some poor soul in the past. Make sure you DO NOT have an allergy to adhesives. Most tapes are latex-free, however if band-aids and other similar products irritate your skin, k-tape may not be in the cards for you. Watch out for body hair. If the area you want to tape is hairy, it may be a good idea to shave or trim the hair before application. The tape will not stick very well if there’s too much hair, as it’s meant for direct skin contact. More importantly, remember this rule of thumb: sticky + increased activation with heat + a few days of activity = OUCH!! when it’s time to peel off. If the tape is itchy or causes more symptoms, remove it immediately. There’s no point in getting a rash or having increased discomfort. The tape has water repellent properties, so pat it dry with a towel after a swim, shower, etc. Due to the heat activation properties of the adhesive, I DO NOT recommended using a blow dryer to get the tape dry (Please refer to #2 for THAT outcome!) Lifesaver tip: the tape is de-activated with oils. So, if you find the tape painful to remove, grab some lotion, baby oil, olive oil, etc. and slowly peel back while applying the oil to the adhesive side of the tape.

 

So, which kinesiology tape is best for you?

When taped appropriately, most products will give positive results and can stay in place anywhere from 3-5 days or more, depending on location, activity, sweat factor, etc.  Again, in order to achieve optimal results and ensure you’re applying the tape specifically for your body’s needs, have a professional teach you first.  That being said, my recommendation for the best go-to brands would be either Kinesio Tape or RockTape. Both have proven to be super effective and tend to last longer than their other counterparts.

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Lyndsay DeFilippo PT, DPT, CKTP received her Doctorate of Physical Therapy from New York University in 2010. She’s a Graston Practitioner and a Certified Kinesiotaping Practitioner. Lyndsay looks at each injury as a constantly changing puzzle, which is only solved when her patient returns to what s/he loves doing. She enjoys helping with the full recovery process, which includes providing the education, tools and fundamentals to prevent re-injury and the potential for new injuries.