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When OTs Wore White Shoes

Insurance Rules

Published June 9, 2014 9:37 AM by Debra Karplus
Being in occupational therapy school in the early 1970s, I have a vague recollection of a very short lecture in an OT Administration class about insurance coverage for occupational therapy, and specifically about Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).  I didn't give the subject much thought as it didn't seem like anything an OT would ever need to know in a clinical setting; the topic of insurance simply lacked relevance to me.

My years as a neophyte OT involved visiting nursing homes and consulting monthly with their activity director.  I spent a few hours each at several of these facilities.  Bingo, group activities, parachute exercises and outings were some of the kinds of recommendations I made as I reviewed individual care plans with the activity staff.  I sent the facility a monthly bill at a predetermined hourly rate as established by a contract, and they paid it.

I took a few years away from the profession in 1979 to be a stay-at-home Mom and also to assist with our family business.  When I returned to the OT arena in 1984, it seemed that everything had somehow changed.    Admittedly, the nature of my responsibilities had changed also, from being an activity consultation to being a clinician who provided direct patient care in a skilled care facility where the majority of the patients on my caseload were covered by Medicare.

Curious, I have recently been searching online to better understand the relationship between healthcare, insurance, and occupational therapy, especially in light of the current Affordable Care Act (Obamacare), that has had the nation in a bit of frenzy for the past several months or so.

The world of healthcare (as did the world, in general) started to become a bit surreal in the 1960s. President Lyndon Johnson signed Medicare into law in 1965.  In 1973, the term "Managed Care" started getting tossed around as President Nixon signed HMO legislation allocating federal funds to promote HMOs.  The concept of managed care opted to help keep rising health care costs under control.  As healthcare providers, we as OTs were earning more money, but for consumers of the healthcare system, costs were skyrocketing at a comparable higher rate.

The concept of Medical Coding and Billing crept onto the scene parallel to the evolution of managed care.  In 1966, Current Provider Terminology (CPT) was established.  In 1979, International Classification of Diseases (ICD-9) evolved.  The 1980s marked the beginning of Healthcare Common Procedure Coding System (HCPCS).  These are all acronyms that are part of our daily, and continuously more demanding, patient documentation in the clinical settings where we work.  The start of HMO-style Medicare brought about some change, as did the current practices resulting from the Affordable Care Act.

Perhaps one of the greatest frustrations of OTs as well as other healthcare provides is that it often seems that insurance coverage has become the tail that is wagging the dog.  The conflict of delivering optimal OT services sometimes conflict with what insurance providers mandate

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