Provider feedback has prompted Highmark Inc. to delay full implementation of a controversial program for a second time.
Last week, the company posted a notice that the "soft implementation" deadline on its Physical Medicine Management Program had been extended from Sept. 30 to Dec. 31, 2012.
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 say the program makes decisions based upon cost to the insurer, not what's best for the patient, and the groups report repeated problems.
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."
PMMP affects physical therapy, occupational therapy and manipulation (chiropractic and osteopathic) services.
PMMP administrator Healthways WholeHealth Networks Inc. authorizes visits based on medical necessity criteria. Highmark itself determines eligible procedures/units based on medical policy for visits approved by Healthways.
As of Sept. 1, Highmark commercial and Medicare Advantage members must be registered with the program at initial visits, and beyond eight visits in a year providers must submit a treatment plan for authorization.
Registration and authorization are still required during the implementation period, but Highmark will not issue denials based on medical necessity or appropriateness.