Highmark Blue Cross Blue Shield Cuts Reimbursement

by Jeffrey Rothman | Apr 11, 2016

Over the past several months the Leadership within PPTA has been involved with several insurance issues created by Highmark Blue Cross Blue Shield (Highmark) with resultant decreasing reimbursement to providers.  The first issue came to light when providers began experiencing cuts in reimbursement beginning in October 2015.  When an inquiry was sent to Highmark concerning these cuts they indicated a notice was mailed out in July 2015 via a “Special Bulletin” however, the PPTA was not able to identify any providers who could recall such a publication.  As far as PPTA can determine, this action was taken unilaterally on Highmark’s part without prior notification nor ability for providers to comment before the decision was finalized.  In the Special Bulletin, Highmark indicated the PID (Pennsylvania Insurance Department) had “approved” this “rate adjustment”.  If there were PPTA members who received the mailing, they likely assumed the “rate adjustment” could not be challenged as it has already been approved by the PID.

     The PID was contacted to inquire about the process that was followed resulting in the “approval” of the rate adjustment.  The PID responded they neither approve nor disapprove rate adjustments from insurers.  We then submitted a request to the PID to provide PPTA with the information Highmark had submitted to the PID.  In Dec 2015 the PID indicated these comments were not public records and could not be provided under Pennsylvania law (40 P.S. 3801.309).  The PPTA responded with a challenge to this regulatory citation however, the PID persisted in their position.  The PPTA felt it was necessary to understand the process behind the “rate adjustment” and submitted a “Right to Know” request.  Currently, the PPTA is waiting for a response to this request from the Open Records Officer of the PID.

     In the January 22, 2016 “Medical Policy Update” Highmark published another unilateral decision in which providers were instructed to apply the 8 minute rule presently utilized by Medicare rather than the American Medical Associations Current Procedural Terminology (CPT) definition of 15 minute/unit time frame currently in place; this requirement will lead to yet another decrease in reimbursement.  This is not a direct rate reduction however; the outcome is the same….less reimbursement to the provider.  Although this was provided as a Medical Policy Update, no application date was published; providers were instructed to contact provider representatives to obtain this information.  When PT providers attempted contacting their representatives, they were given differing start dates.  The PPTA is seeking clarification on a definitive implementation date for this policy change.

     Another payment issue Highmark has created was a change to the PMMP (Physical Medicine Management Program) process.  Highmark again made a unilateral decision to define certain CPT codes as Physical Medicine, Occupational Therapy, or Manipulation.  In order for a Physical Therapist to utilize and be reimbursed for certain CPT codes Highmark has defined as Occupational Therapy, the Physical Therapist is required to indicate they are providing Occupational Therapy Services.  It is our contention that forcing a physical therapist to indicate the therapist is performing Occupational Therapy Services is in violation of both the PA State Physical Therapy and Occupational Therapy Practice Acts.  This has been an ongoing dispute with Highmark over the delineation of the various codes which Highmark is using to define specific professional services.  On several occasions, PPTA has attempted to educate Highmark that any provider, as long as it’s within the scope of their practice, is permitted to utilize appropriate CPT codes, which is consistent with the AMA position on use of CPT codes.

     While all this is occurring, Highmark indicated they are going to cut reimbursement rates yet again; this cut is to take effect in April 2016.  This notification was just received from Highmark and involves nearly every provider, including physicians.  The reason provided in the notification for the cuts was that Highmark actuaries made a mistake in determining rates for ACA (Affordable Care Act) products and this error would require a “rate adjustment”.  This “rate adjustment” amounts to a further decrease in reimbursement to providers.  PPTA does not agree that Highmark’s inability to accurately calculate revenue should be compensated by passing rates cuts to providers, especially those who have already experienced several cuts in payment over the last several months by Highmark’s action.

     The PPTA has been working on these issues with the PID as well as the DOH (Department of Health) in an effort to stop Highmark from implementing unilateral changes which have detrimental effects on providers and subsequently to care provided to our patients.  In addition to working with the PID and DOH, we are currently developing a plan to contact Pennsylvania Legislators in order to explain the effect these arbitrary and unwarranted cuts are having on our members and the patients we treat every day. 


Gregory L. Waite, PT, DPT

President, PPTA