,Highmark Inc. ,Insurance ,Health Care and Hospitals ,Health Care Reform

Highmark announces soft start on controversial PMMP

By - Last modified: September 6, 2012 at 9:24 AM

A new authorization program that has drawn protests from providers has been given a monthlong soft start, according to Highmark Inc.

The Physical Medicine Management Program, administered by Healthways WholeHealth Networks Inc., provides medical necessity review and authorization for physical therapy, occupational therapy and manipulation (chiropractic and osteopathic) services.

As of Sept. 1, Highmark commercial and Medicare Advantage members must be registered with the program at their initial visit, and beyond eight visits in a year the provider must submit a treatment plan for authorization.

On Aug. 29, Highmark announced that it would not issue any denials based on medical necessity or appropriateness before Oct. 1, to give providers time to become familiar with the system.

Groups including the Pennsylvania Chiropractic Association, Chiropractic Fellowship of PA, PA Occupational Therapy Association and PA Physical Therapy Association have mounted a campaign asking legislators and the state insurance department to intervene and ban Highmark from implementing PMMP.

The groups characterize the program as "a secret and unproven computer software program that makes decisions based upon cost to the insurer, and not what's best for the patient."

In news releases about PMMP, Highmark said in 2010 it paid more than $100 million for chiropractic-related services, second only to cardiac care, and nearly $100 million for occupational and physical therapy combined and believes "close to one-third of these claims may not represent optimal utilization."

The implementation, Highmark said, "is due, in large part, to increasing demands from our employer group customers for products that promote quality, medically appropriate care and value for their employees."