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Major commercial insurer Aetna recently provided some clarification on policies related to payment for physical therapy, and it's good news for physical therapists (PTs) and their patients.
The clarifications help to answer questions related to the company's physical therapy policy, specifically around payment for evaluations and the ways direct access provisions can affect payment. Here's what Aetna said:
Evaluations could be eligible for payments sooner than the 180-day wait period.
Although Aetna’s policy reads that "physical therapy evaluations will be eligible for payment once every 180 days," Aetna representatives have informed APTA that evaluations performed within 180 days of the original evaluation may be allowed upon reconsideration or appeal, providing the evaluation is for a new or unrelated condition.
State direct access provisions could allow for reimbursement from Aetna without a referral.
Aetna’s policy reads that “Aetna considers physical therapy medically necessary when this care is prescribed by a chiropractor, DO, MD, nurse practitioner, podiatrist or other health professional qualified to prescribe physical therapy according to state law." Representatives from Aetna have clarified that in states with direct access provisions for PTs, a PT is considered an “other health professional qualified to prescribe physical therapy,” meaning that PT services will be reimbursed without an order or referral if all other requirements are met.
"Aetna has been working with APTA to support access to PT services, and understands the importance of making providers aware of how specific policies are interpreted," said Alice Bell, PT, DPT, an APTA senior payment specialist. "We appreciate Aetna's efforts and look forward to continued cooperation on issues that may impact access to care."