Physical Therapy - Student Health Insurance Claim Review

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Team ID: 
959
College / Administrative Unit: 
Student Affairs
Date Started: 
October 2010
Objective: 
The purpose of this study is to identify claims being reviewed by United Healthcare Student Resources (UHCSR) for additional documentation and claims being denied as maintenance physical therapy services. Students are allowed 12 visits or 4 weeks of services prior to review under the UHCSR policies. Denied charges after the services have been provided are a barrier to students continuing to seek necessary treatments in physical therapy and creates negative “word of mouth” advertising for University Health Services (UHS).
Desired Results: 

This has not been previously specifically tracked. Therefore, going forward, Physical Therapy (PT) and Student Health Insurance (SHI) will identify claims to be tracked based upon student letters from UHCSR brought in to UHS. This will be tracked on an excel spreadsheet and reviewed within one year to identify trends in claim review and denials for PT services at UHS by UHCSR. The goal is to have 95% claims reviewed approved for payment as non-maintenance (or acute) services.

To address the outside provider documentation issue, we created a “memo” to be handed out to students when they are given a referral by UHS for orthopedic services. The memo will advise the student(s) that if they need PT services and choose to have the services outside of UHS, rather than come back to UHS PT, they may have a greater out-of-pocket charge for which they are responsible.

Memo was drafted and approved by Doris Guanowsky, Sr. Assoc. Director, and Beth Collitt, Marketing Manager, as of February 7, 2011. Once this was approved, the information was provided to the Referral staff via Nicki Shunk on February 8, 2011.

PT and SHI will continue to monitor this situation and report again in Spring 2012.

Nancy Lambert
November 10, 2011

1) The changes implemented in Spring 2011 resulted in a total of zero physical therapy claims being denied for services being provided by University Health Services (UHS) Physical Therapy.

2) The issue continued to be the physical therapy services provided outside of UHS that required a review of medical records after 12 visits to determine if there was progress in the therapy or if it was a matter of maintenance. Students continued to struggle with this after the services had already been provided denial.

3) It was determined to discontinue this effort as a new Penn State student health insurance plan vendor had been selected for Fall 2012. The new provider and benefit for physical therapy of 40 visits should remove the after the fact denials for services outside of UHS. If the issue re-arises under the new vendor, Aetna Student Health, then a new QI effort will be started.

Karen Kline
August 17, 2012

Name: 
Nancy Lambert
Members:
  • Karen Kline, Leader
  • Linda Eck, Member