New York State, Physical Therapy and High Co-Pays

(Article co-authored by Brandi Hale and Sean Santagato)

What Is The Issue?

There has been a growing trend for health insurance carriers to designate physical therapists as “specialists” for purposes of co-payments (the same as cardiologists, neurologists, etc).  This designation has caused a remarkable cost-shift from insurance carriers to their subscribers, in turn having a significantly adverse impact on co-payment levels.  Essentially, the “specialist” category enables insurance plans to impose on consumers higher specialist co-pays instead of the lower primary care visit co-pay that plans previously required for physical therapy care. 

How Does This Impact You As A Practicing PT?
The high co-pay rates are seriously limiting access to physical therapy care for many patients and forcing consumers to self-fund physical therapy care even though they or their employer are paying thousands of dollars for health insurance.  At present is it the norm for co-pays to account for 60-90% of the maximum allowable on a visit.  This deters patients from continuing physical therapy and therefore costs you money.

Here Is An Example…
A patient seeks out your care and expertise for their low back pain.  Their insurance carrier’s payment rate for each visit is $55 maximum allowable and the patient has a $50 co-pay for each visit.  This means your patient is paying 90% of the cost of the visit or $50 while the insurer is paying only $5 per visit.  Ideally you would like to see your patient twice a week for at least 4 weeks for a total of 8 visits.  So your patient is expected to pay $50 for each of the 8 visits, for a grand total of $400. 

What Is Being Done?
The NYPTA is asking members of the State Legislature to support bill S.4321 sponsored by Senator Breslin and A8171 by Assemblyman Cahill to end the imposition of additional co-pays on New Yorkers for physical therapy services on the basis of provider or setting.  The NYPTA is advocating for this bill which would limit co-payments to no more than 20% of the reimbursement paid to the physical therapist.

What Can You Do About The Extremely High Co-Pays In New York?
1. Attend Lobby Day on Tuesday May 17, 2011 as a Legislative Advocate

2. Write letters to your New York State Legislators asking for their support on bill S4321

3. Sign a petition to support fair co-pays for physical therapists

4. Fill out the attached questionnaire requesting information on insurance carriers, co-payments and the allowed benefit amount per carrier for patients that you are currently treating.  Return the questionnaire to Kelly Garcaeu, Assistant Director of NYPTA Reimbursement

5. Become an active member of the APTA and chapter member of the NYPTA                                                    (www.apta.org) (www.nypta.org)                     
Register for Lobby Day:
www.nypta.org

Find Your New York State Senator:
www.nysenate.gov/senators

Find Your New York State Assemblyman:
www.assembly.state.ny.us/mem/

Sample Letters Found At:
http://www.nypta.org/i4a/pages/index.cfm?pageid=3812

Sign Petition:
http://www.thepetitionsite.com/2/FairCoPays-BetterResults-2010/

Return Questionnaire To Kelly Garceau:
Attn: Kelly L. Garceau
Reimbursement Director
New York Physical Therapy Association
5 Pallisades Drive, Suite 330
Albany, NY 12205