Friday, June 28, 2013

Remember what was in the 2013-2014 NYS Executive Budget?

Go and remind yourself of Governor Cuomo's ideas for Early Intervention!!


Providers, please remember! If the Governor had his way you would have been negotiating rates directly with third party payors.  NOW they say "Go ahead and just accept whatever they are willing to pay."

NEXT YEAR they will probably try to put this language in again - and then you will regret JUST ACCEPTING whatever they are willing to pay.

Sorry for the CAPS, but everyone needs to understand this and write a letter to the Bureau of Early Intervention and tell them that you WILL NOT just accept what third party payors offer and that there MUST be some allowance for negotiating reasonable rates because we KNOW what the State's intention was and we KNOW that all this is still heading down the same path as soon as the Governor has another opportunity to submit his ideas in an Executive Budget next year!

Every Early Intervention provider needs to know that the County Escrow is just a short term plug and that the State's intention is to privatize the program and have you negotiate directly with insurance companies.  You must be aware that there are implications if you JUST ACCEPT what those commercial insurers pay.

If you don't get a reasonable rate from the insurance companies today, don't count on getting a reasonable rate from them tomorrow, unless someone twists their arm and makes them do it!

You have a County Escrow safety net this year that makes up for whatever the commercial insurance will not pay - but will it be there next year when Governor Cuomo tries to insert this language into the budget and further privatize the program???

I believe that there is nothing to fear about privatization and I think that cost savings can occur in such a system - but not if providers are improperly set up for failure by tricking them into accepting anything that the insurance company will pay!!  
Payment schedules and your future will depend on PRECEDENT and NEGOTIATION.  Not CAPITULATION.

Thursday, June 27, 2013

Unintended consequences of NYS Early Intervention Payment Policies

We received this email from the NYS Bureau of Early Intervention today. I would like to advise providers as well as the Bureau of the potential unintended consequences of this policy
Dear Colleague:

The Bureau of Early Intervention has recently received numerous inquiries regarding agreements being sent to EIP providers by insurers or insurer clearinghouses in response to claims submitted for EIP services. The agreements ask EIP providers to accept claim amounts proposed by the insurer as payment in full from the insurer for the claim which are lower than the State-established EIP rate.

This is to advise EIP providers that providers should sign and return these agreements to insurers as requested. The agreement is specific to each claim. The interim State Fiscal Agent, McGuinness, is tracking all reimbursement from insurers to individual providers. The balance owed to EIP providers who receive a payment less than the State-established rate for EIP services from insurers will be included in Key Bank payment files and reimbursed through the escrow account.
Please note that the language in insurer payment agreements which states that the provider must accept the insurer’s payment as payment in full does not apply to payments from the escrow account. Nothing in this language prohibits payment to the provider by the municipality from the escrow account. However, it is recommended that prior to signing and returning the agreement to the insurer, providers cross out “financially responsible party” and insert “payor”. This can be hand-written on the agreement, so that the sentence in the agreement reads as follows:
“Provider agrees not to bill the patient or the payor for the difference between the Billed Charge and the Expedited Amount."
This will make it clear to the insurer that the provider will not bill either the child’s parent or the payor for the difference between the insurer’s rate and the State-established rate for the EIP service.
Please do not reply to this e-mail announcement.
Thank You.

Insurance companies will do their level-best to pay the most ridiculously low reimbursements, as is common practice. We experience some insurance companies who try to reimburse outpatient occupational and physical therapy services at the outmoded rate of $2.35 per unit. This was the Medicaid rate many years ago and this rate is still present in their fee schedules. Periodically, we have insurance companies attempt to reimburse us at this rate. When this happens, we make a concerted effort to remind the insurance company of the proper contracted rate for the therapy service and in general the reimbursement is adjusted.

When no one 'fights back' about the very low rates that are sometimes attempted, the insurance companies use this rate as a basis for determining the 'community standard.' For example, when I entered private practice there was one HMO who paid $2.25 a visit and the family had a $15.00 co-pay. It took many years of advocacy to get the HMO 'share' of that fee up to a reasonable level. The reason why that HMO 'share' languished at such a low level for years is because NO ONE FOUGHT IT. Hospitals and other community health care providers were just accepting it, and it wasn't until private practitioners started pushing back that reimbursements were brought up to a reasonable level.

I understand how some might argue that private practice raised the cost of care, but in actuality private practice and other providers finally fighting back raised the reimbursements to a level of respectability. Even under current rates that are commonly reimbursed, the reimbursements are significantly below the early intervention standards.

The fact is that changes to the NYS insurance law have dumped early intervention responsibility to the commercial carriers and this is a threat to global reimbursements if we follow a policy of just 'accepting' the amount that the insurance company wants to pay. Early Intervention providers may not think it matters to them because the County escrow funds will just make up the difference. This would be a terrible error in thinking. In reality, allowing the commercial carriers in the State to set the bar so low will suppress salaries because lower reimbursements mean lower wages for everyone (in a global sense).

I am obviously not advocating for any global effort to set fees - that is definitively NOT LEGAL and that is NOT my intent. However, I am advocating for practitioners to understand the implications of 'just accepting' what the commercial insurer pays. Practitioners (and their State Associations) should advocate for fair and reasonable reimbursements from commercial and all other carriers because this impacts everyone, directly and indirectly.

JUST BECAUSE Early Intervention providers have a 'safety net' of the County Escrow, that does not mean they should blindly accept whatever commercial carriers try to get away with. Accordingly, County administrators and lawmakers should expect that commercial carriers will attempt to play low-balling fee schedule games with the Early Intervention Program because that will be an end-around to the intent of getting some private cost-sharing that helps distribute costs for delivery of this program.

Thursday, June 13, 2013

On arthritic knees and the hope of telerehabilitation

OK so there are days when I start wondering how many years I am going to spend crawling around on the floor with children.  Sometimes I just wonder how many miles are meant to be crawled in a lifetime.  This leads to thoughts about how appealing academia might be where I can spend a greater amount of my time sitting instead of running/hopping/crawling/etc.

The concept of telerehabilitation appeals to me - instead of/in addition to academia maybe a career in telerehabilitation is another option for my decrepit knees?  I have no inherent bias against telerehabilitation; in fact, I kind of think it would be great to find out that some types of OT treatment could be effectively delivered in a distance format.

Our regulatory system is miles behind the telerehabilitation movement.  I attended a well publicized telerehab 'continuing ed' seminar recently and hoped to have some questions about regulations answered, but they really didn't have any.  I have 'continuing ed' in quotes because I am not sure if it was continuing ed as much as it was a cheerleading session and maybe a marketing ploy.  I noticed that a press release announcing OT being added to the company's telerehab services came out the day after the webinar.  Apparently this company is providing 'online OT' within the context of 'online charter schools.'  That hardly represents a standard context so I don't really even think that there is a lot of 'telerehabilitation' happening in a pediatric school-based context.

Still, even if my knees are not so springy my hope springs eternal - I was happy to see an article published entitled School-Based Telerehabilitation in Occupational Therapy: Using Telerehabilitation Technologies to Promote Improvements in Student Performance.   Unfortunately, the article was a little disappointing. 

I expected a pilot study of some sort but as happens often, researchers overstate their results which is unfortunate because the cheerleading crew does not looks at these things with a discerning eye.  That makes us look like we aren't really very serious about producing high quality evidence.

In this particular study the researcher used The Print Tool which is a non-standardized tool that is used to assess handwriting.  This tool is probably fine to use on an informal basis in a clinical context for comparing a child's performance to themselves in a pre-test post-test fashion.  At the least it sets some moderately objective parameters and attempts to operationally define some parameters about writing.  However, it is not norm-referenced or even criterion-based, and so there are no associated standard errors of measurement that we can consider.  We have no real way of knowing how sensitive the tool is and if measurement differences have any meaning.  We also have no reported data on reliability.  These issues are important but forgivable if we are just using something for informal clinical use as a tool to look at progress, but this is definitely not a tool to be using in a research context.

That was just the beginning of the concerns.  No control group.  No blinding.  Small sample size.  Very short treatment duration (only 6 sessions).  The research design just does not provide any reason whatsoever to consider the results significant in any way.

This is not to say that future studies won't show that telerehab models are effective, but so far all we are seeing are cheerleading sessions from agencies that are already in the field trying to drum up support for the model and really poorly done research that doesn't begin to hold up under any kind of scrutiny.

Anyway, my poor broken down knees did not get any relief or hope that telerehabilitation in pediatrics is effective.  But I will still keep looking.


Criss, M. (2013). School-based telerehabilitation In occupational therapy: Using telerehabilitation technologies to promote improvements in student performance. International Journal of Telerehabilitation, Available at: <>. Date accessed: 13 Jun. 2013. 

Thursday, June 06, 2013

Child passenger safety: A question about the epistemic culture of occupational therapy.

Well.  I sometimes write the titles to my blog posts before I write the posts themselves.   That is what happened with this post, but now I am derailed but I am going to keep the title because it is still apt.

I just finished reading the June 3, 2013 issue of OT Practice.  The cover story is entitled 'On the Go: Safely Transporting Children with Special Health Care Needs.'  This is an excellent article, full of practical and relevant information about the topic.  The Riley Hospital for Children at the Indiana University School of Medicine has blazed this trail for years and years - and that fact bothered me because I could not understand why I was reading yet another article about child passenger safety as if it was the first article being written.  I totally appreciate the article; I just don't want to see any more calls arguing about HOW or WHY this is a legitimate area of concern.  I think it should be established by now.

That cause me to begin a search for all the other Child Passenger Safety articles I knew existed - many in our own literature.  I know there was a great AJOT article written by Dr. Bull and other Indiana University folks in the 1990s.  I thought I remembered an earlier article written about how to actually adapt a car seat for a child who had a spica cast.  Those were the old days - now commercial products are available and making adaptations is not recommended - but I wanted to show how places like Riley have been banging this drum for years and years.  I couldn't find that article - and I was starting to wonder if articles get purged from databases when they recommend things that we know we shouldn't be doing any more (like cutting car seats!).

Anyway, then I started thinking about Taube Korn and I was remembering an excellent article that she wrote in Pediatrics and I remember emailing with her about her guest editing an issue of the Israeli Journal of Occupational Therapy on child passenger safety and on other topics we were both interested in.  Here I was thinking that I hadn't heard anything about Taube lately and it was a long time since I emailed with her and I found this blogger site that indicates she passed away in 2010.  Then I followed a few links and found this site which is from the hospital where she worked.

So I am derailed.

I was planning to engage a conversation about transfer of knowledge in the field and why we re-introduce topics over and over when they probably should be established in our practice.  Child passenger safety is not the only topic that we tend to do this with.  Hospice care is another great example.  Seminal work was done in the 1970s and 1980s but we still see articles popping up now and again arguing that OT has a legitimate role in hospice care.  That upsets me.

I think we honor Taube's work (and in the case of hospice we honor Kent Tigges and Bill Marcil) by starting to do a deep dive into this knowledge transfer problem that keeps us in a Groundhog Day cycle of reintroducing the topics over and over again.

But I am derailed, so I will argue another day.