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When 80 percent is considered a cure: Understanding HMO definitions

February 9, 2005

Physical therapists help people repair injured muscles, bones, joints and ligaments, but more and more patients are being rejected from their physical therapy benefits before their treatments have fully progressed.

A White Plains, New York based company called OrthoNet manages three of the region's largest HMO's, including Oxford, Empire Blue Cross Blue Shield and Cigna. Just like some companies manage drug, dental or visual benefits based on percentage figures to determine coverage, physical therapists have begun to notice a trend in policy denials among patients when their treatment progress has reached 80-percent.

According to Jim Nugent, from the American Physical Therapy Association, he gets around five complaints about OrthoNet for every one he gets about all the rest of the country's benefits-managers, including complaints that OrthoNet cuts patients off when they have achieved 80-percent healing.

Initially, the Medical Director of OrthoNet, Dr. Robert Refowitz, said the 80-percent figure was made up by physical therapists, but WNYC obtained OrthoNet documents titled "Discharge Criteria" clearly indicating the company does use the 80 percent practice. The papers cover a variety of conditions, with each one stating at the top of the page that "OrthoNet's discharge criteria for range of motion, strength and function are defined as 80-percent of established normal values," according to WNYC.

After initially declining the opportunity to be interviewed, Refowitz spoke to WNYC after being confronted with company documents. Refowitz says OrthoNet is upfront to therapists about its definition of wellness, and it is the primary insurer's job to set policy and keep patients informed. For patients and therapists this information, which is required by New York state law if asked for by the consumer in writing, is very difficult to get.

Inquiries by WNYC into physical therapy coverage at several of the region's largest HMO's resulted in the same response – the information is part of the "medical review process," beginning after treatment is started.

Eliot Spitzer's chief healthcare enforcer, Joe Baker, says patients have a right to that information as a means to shop for healthcare and once they have enrolled in a plan and have been denied care. Spitzer has sued New York HMO's, which frequently violate this law, according to Baker's office, and a settlement is being worked out.

According to Baker, OrthoNet's exclusion of "return to sport, recreational or vocational activities" probably meets the standard of being so broad they are openly stated.

If you believe you have been unrightfully denied physical therapy coverage, please contact our consumer fraud lawyers today.