Highmark hopes to prevent unnecessary medical use and, therefore, help reduce costs by requiring prior authorization for certain therapy services and chiropractic visits, starting in the fall.
The Pittsburgh-based insurer will require that its members obtain pre-authorizations if they want to receive more than eight visits worth of physical therapy, occupational therapy and chiropractic services. Highmark chose the eight-visit pre-authorization threshold because nearly two-thirds of its members' therapy and chiropractic needs are met in that timeframe, reported the Pittsburgh Business Times.
"This program is one of a number of efforts that Highmark is taking to help reduce unwarranted variations in the delivery of healthcare and to help manage rising healthcare costs," Virginia Calega, Highmark's vice president of medical management and policy, said in a statement.
Chiropractic care pre-authorizations is a priority for Highmark because it's the second-highest paid service for its members, for which it spent more than $100 million in 2010. The chiropractor's "scope of license [is] fairly broad," and includes adjustments, massage therapy and electrical stimulation therapy, Calega told the Pittsburgh Post-Gazette.
"We had a fair number of people getting five, six, seven services" in one visit and Highmark was billed for each of them. Because about one-third of those payments probably don't represent optimal utilization, Calega said, Highmark hopes to eliminate them from the system.
The new policy takes effect Sept. 1 and applies to all Highmark members insured through employer-based group plans in Pennsylvania and West Virginia, plus individual and Medicare Advantage members.