According to researchers from Johns Hopkins, HHS, and NIH, enhancing non-pharmacological coverage such as physical therapy and chiropractic care can improve outcomes, increase cost-effectiveness and reduce opioid use. Payers reimburse licensed physical therapists, chiropractors, and occupational therapists for their services. Medical billing and coding services are available to help providers submit accurate claims and maximize reimbursement. These alternative therapies are now recommended as effective strategies to help manage pain and limit reliance on opioids.

Opioid Use

Giving patients an opioid may be the quickest solution to ease pain, but opioid-related overdoses accounted for 66.4% of the 63,632 overdose deaths in the United States in 2016, according to a study from the Centers for Disease Control and Prevention (CDC). The American Academy of Pain Medicine reports that 100 million Americans live with chronic pain, and many of them rely on opioids to manage it. The rise in prescription opioids plays a significant role in fueling the national epidemic of fatal overdoses. The CDC recommends nonopioid options like physical therapy for the safe management of chronic pain.

Published in JAMA Network Open, the new study explained that, acting in response to the HHS’s National Pain Strategy, some payer groups may adopt best practices to reduce dependency on opioids. By expanding coverage for physical therapy, chiropractic, and acupuncture service, payers can provide beneficiaries with affordable and clinically proven pain treatments, while cutting dependency on opioids.

The U.S. National Pain Strategy specifically recognizes the value of chiropractic care for pain management. A study published by the Canadian Chiropractic Association in 2016 cited research which found that combining spinal manipulation with strengthening exercises have a comparable effect to the prescription of nonsteroidal anti-inflammatory drugs and exercise, and may speed up recovery and improve outcomes while decreasing the reoccurrence of injury. The report also noted that spinal manipulation in conjunction with standard medical care has been clinically proven to be a viable, non-invasive, and evidence-based approach to managing musculoskeletal-related pain and dysfunction.

An April 2018 report from Physical Therapy (PTJ), the official scientific journal of the American Physical Therapy Association (APTA), stressed that early administration of physical therapist treatment can reduce opioid use and downstream health care costs. Research published in the PTJ May special issue revealed that:

  • Patients who received physical therapist treatment immediately following arthroscopic hip surgery had lower downstream costs and lower opioid use.
  • Physical therapy treatment within three days of the onset of low back pain was associated with lower total health care costs and lower opioid use.
  • Older adults with low back pain improved physical function via telehealth physical activity programs.

The JAMA study pointed out that many payers considered acupuncture, chiropractic treatment, physical therapy, and steroid injections as medically necessary services and provided coverage for these non-opioid pain management and treatment services. However, they usually limit the duration of services or require administrative actions which could affect care delivery. For instance, some of the exclusions and conditions of the reimbursement policy of Blue Cross Blue Shield of Minnesota include:

  • Blue Cross will not reimburse providers for massage or manual therapy services (97124 and 97140).
  • Coverage for massage and manual therapy services provided without a chiropractic manipulation is subject to the subscriber’s contract benefits. Some benefit plans may not cover this service.
  • Blue Cross will allow 24 visits annually, before requiring prior authorization for Minnesota Health Care Programs subscribers. Providers are required to obtain prior authorization for any visits in excess of 24 annually.

The researchers also pointed out that:

  • Medicare Advantage (MA) plans also classified chiropractic care and physical therapy as key medical benefits, but felt that acupuncture was not a treatment to address immediate clinical needs.
  • There was not enough information from commercial and MA payers to determine if psychological treatment was deemed by payers as a medically necessity for lower back pain treatment.
  • Coverage utilization varied between private and public payers, with Medicaid less likely to cover acupuncture or psychological services for back pain.
  • While over 80 percent of Medicaid plans covered physical therapy and chiropractic care, only 13 percent of Medicaid plans covered acupuncture and 20 percent covered psychological treatments.
  • Every Medicaid plan surveyed had visit limits for physical therapy and 92 percent of plans capped beneficiary visits for chiropractic care. Fifty percent of Medicaid plans had prior authorization requirements for acupuncture services and 75 percent of Medicaid plans had condition requirements that had to be met before accessing chiropractic services.
  • Utilization management policies were common in a majority of private plans.
  • 67 percent of commercial and MA plans had visit limits on physical therapy and 62 percent of plans had limits on chiropractic visits. Seventy-five percent of MA plans restricted coverage requirements for chiropractic services to patients with spinal subluxation.
  • Only 33 percent of commercial and MA plans required prior authorization for physical therapy services.
  • Out-of-pocket costs for patients receiving non-opioid treatments for lower back pain varied between in-network and out-of-network utilization. Private plans required a fifty percent copay for out-of-network care while MA plans required a 35 percent copay.
  • Both private and commercial payers are inconsistent when it comes to covering non-pharmacological benefits that improve overall health.

The researchers concluded that payers may need to enhance patient access to chiropractic or lower back pain services that do not include opioid treatments. This will divert patients away from potentially addictive opioids for long-term pain. Public health policies that better guide care delivery and reimbursement should encourage the use of evidence-based, nonpharmacological treatment options, the team noted.

When it comes to reimbursement, chiropractors and physical therapists need to submit claims with correct diagnostic and treatment codes and modifiers. Partnering with an experienced medical billing outsourcing company that has a well-trained team to provide chiropractic and physical therapy billing and coding services can ensure healthy accounts receivables.