Commercial payers need advocacy too

Advocacy (noun) is the act or process of supporting a cause or proposal. AOTA is, among many things, an advocacy organization. Generally, when occupational therapy practitioners (OTPs) think of AOTA’s advocacy efforts, their thoughts turn to our excellent advocacy in Congress (recent examples include the Lymphedema Treatment Act and inclusion of occupational therapy in telehealth extensions); and with federal agencies, including the Centers for Medicare & Medicaid Services (CMS) and the Department of Education. Many practitioners may also think of advocacy efforts at the state level, most notably the interstate licensure compact, as well as with state licensing boards and State Medicaid agencies. But few practitioners realize that AOTA’s advocacy efforts extend to commercial insurance companies and their subsidiaries. 

Payer Advocacy 

Advocacy at the federal and state levels follows standard pathways for communication and opportunities to provide input. However, advocacy with commercial payers takes a somewhat different route because commercial payers are private companies. They are not required by state or federal law to respond to input from the public, including associations, and they can create proprietary benefit structures, including medical and reimbursement policies. However, there are parameters within which payers must operate, depending on the line of business. For example, plans offered by large employers and offered under an employer’s benefit package must follow rules established by the Employee Retirement Income Security Act (ERISA). Other plans must operate within the guidelines of the state department of insurance. Furthermore, plans must abide by the Affordable Care Act (ACA). And if plans are Medicare Advantage (Part C) they must follow rules as outlined by CMS in the Medicare Managed Care Manual (Centers for Medicare & Medicaid Services. (n.d.), and Medicaid managed care plan must adhere to the state’s Medicaid requirements. Needless to say, payer advocacy can be complex and often confusing.  

What Can Practitioners Do 

As a practitioner, it can often feel like you are beholden to insurance companies, and that is true to a certain point, especially if you are a contracted provider. However, practitioners are not helpless and should never feel like issues with payers are foregone conclusions. Awareness and self-advocacy are simple activities that can have a big impact on the day-to-day operations of occupational therapy practice. First, make sure you read your contract and understand the terms. Yes, it is tedious, but if you signed a contract and the terms at issue are delineated within, it can be difficult—if not impossible—to change something to which you have legally agreed. Second, read the bulletins sent out by the payers you interact with—not just the ones you are contracted with (i.e., stay up to date on payers where you are both in and out of network.) Bulletins are how payers give practitioners notice of upcoming changes to medical and reimbursement policies. AOTA provides a resource for practitioners to use when reviewing contracts and policies that can be found under Payment Policy in the Practice Essentials section of the AOTA website (https://www.aota.org/practice/practice-essentials/payment-policy/pay1). If a new policy is at issue, then practitioners should contact AOTA and their state association. This leads us to the last recommendation on how practitioners can engage in advocacy—by being members of and engaging with AOTA as well as state associations. Why both? As a national Association covering the entire country and territories, there are innumerable insurance companies out there that are state or regionally based—too many for AOTA to track each and every one individually. Therefore, AOTA primarily focuses on what we refer to as the Big Five: United Healthcare (UHC), Aetna, Cigna, Humana, and Anthem. These are large payers that cover multiple states or regions. We maintain points of contact with each organization and collaborate with other associations and coalitions to advocate with these large companies. For the smaller state or regional-based payers, AOTA relies on the state associations to lead collaborative advocacy efforts. Maintaining open lines of communication is critical in these instances. AOTA and state associations need members to bring issues to our attention and provide supporting documentation for them. This may include copies of policies, examples of denials, and provider manuals. We rely on this information from members because many insurance companies keep information like this behind a provider portal that can only be accessed with a National Provider Identifier (NPI) or similar sign-in information that AOTA, and often state associations, do not have the ability to access. 

Examples of AOTA Advocacy in 2024 

One issue that AOTA spent a significant amount of time and effort on in 2024 was the announcement in August that UHC would implement a prior authorization process for occupational, physical, and speech therapy, and chiropractic services for their Medicare Advantage plans. AOTA jumped into action, collaborating with coalition partners from several industries to initiate an advocacy effort. We started with a letter to UHC, outlining our concerns with prior authorization in general, highlighting UHC’s previous declarations that they were eliminating many prior authorization requirements, and requesting a meeting with UHC. After two meetings with UHC executives where AOTA and others requested that the prior authorization requirement be rescinded, AOTA took the next step in advocating for practitioners and their clients by reaching out to CMS to request a review of UHC’s prior authorization process and policy. The meeting with CMS was very productive, and that effort is still underway. After these advocacy efforts, UHC announced they were going to waive prior authorization for occupational, physical, and speech therapy, and chiropractic services for the initial six visits of an episode. Although we see this as a win and appreciate the effort to alleviate some of the administrative burden associated with requesting prior authorization for occupational therapy services, AOTA will continue to advocate for OTPs and their clients to completely remove this unnecessary barrier to care. 

In a smaller but equally important effort, AOTA collaborated with the Connecticut Occupational Therapy Association (ConnOTA) to remove a capitated reimbursement rate as announced by Anthem BCBS of Connecticut. Anthem announced in July 2024 that they would be capping reimbursement for occupational therapy services. AOTA was able to work with ConnOTA on a letter advocating against this reimbursement methodology, which ConnOTA then sent to Anthem. This led to a meeting with Anthem staff in which ConnOTA and AOTA were able to articulate how a capitated reimbursement would negatively impact clients and the OTPs who care for them. Simultaneously, ConnOTA initiated an informational campaign for private practice owners and their clients. As a result, in October 2024, Anthem announced they were rescinding the capitated rate for further evaluation. Congratulations to ConnOTA for this advocacy success! 

What 2025 Holds for Commercial Insurance Companies 

AOTA anticipates that there may be many changes related to private insurance this year. At press time, AOTA staff were monitoring Executive Orders that may impact the payer community, as well as Executive Branch agency staffing changes under the new Administration, including CMS and the Department of Health and Human Services, and the issuance of a final rule related to Medicare Advantage that was proposed under the Biden Administration. The new Administration and Congress may also have new policy priorities, such as incentivizing Medicare Advantage plans to provide more innovative offerings, or prioritizing management of chronic conditions. Likewise, changes to the Affordable Care Act, such as what care is considered a preventative service, or changes to the essential health benefits, could lead payers to make broad changes to their policies and benefit structures. As always, AOTA will keep abreast of any changes impacting OTPs and their clients and issue updates accordingly. In the meantime, questions about or concerns with commercial payers can be addressed to AOTA’s Regulatory Affairs staff at Regulatory@aota.org. 

Reference 

Centers for Medicare & Medicaid Services. (n.d.). Medicare Managed Care Manual (Publication #100-16). https://www.cms.gov/regulations-and-guidance/guidance/manuals/internet-only-manuals-ioms-items/cms019326  

Julie Lenhardt is AOTA’s Manager of Reimbursement and Regulatory Policy.