September 19, 2019

Anthem Blue Cross

Attn: Enterprise Provider Education

PO Box 62756

Virginia Beach Va 23466

PEducationZ4@anthem.com

1-844-405-4294

Re: Claims Review

Dear Enterprise Provider Education department:

Thank you for your letter dated September 11, 2019, informing us our over usage of procedure code 97110 therapeutic exercises.

I hereby in this letter offer you the reasoning our clinic applies in treating patients who come to our clinic to help you understand why that code is used and what it does.

Patients seen in therapy are usually prepped for manual therapy (Hands-On work) by using a modality to warm them up as performing manual therapy on a stiff extremity will not just cause pain but it will be detrimental to progress since it may cause micro trauma. Patient are then seen for manual therapy to help increase range, decrease pain or help with improving strength.

The gains made in therapy with manual mobilization must be maintained by patient using the body part in that new available range. They need to activate the tissue in the newly gained range. If they do not do that then the body returns to the maladaptive resting length, it acquired due to disuse. An example I can give you is a door stuck due to moisture absorption. As you move it more it gets looser, if it is not moved then the door fails to move and it permanently stuck.

Another reason we use therapeutic exercise in the clinic is to ensure that the patient is doing the exercise correctly. Many times, what we instruct the patient to do and what they remember and do at home is not just counter productive but harmful as they do it incorrectly delaying progress and sometimes causing new problems. Monitoring their exercises in clinic assists us in timely upgrading of the exercises to progress them to the next level while still ensuring accuracy. Without timely upgrades patients not just fail to progress but return with new problems (lack of proper exercises after impingement for shoulder results in the returning with tears in the supraspinatus)

Also, in order to ensure accuracy with follow up of exercises we make videos on their cell phones besides giving them a paper to do the exercises. The video ensures correct visual instructions on them, so they are aware of doing those exercises and ensuring buy into the program as they get better results.

Gains made with our Hands-On mobilization techniques followed by therapeutic exercises prevents surgeries. This low cost in therapy (procedure code 97110) prevents costly surgeries or revisions or complications. We take pride in our work and present ourselves as leaders in upper quadrant rehab. I would encourage you to compare our data with the complicated cases we see to that of others in the area and see how many surgeries we have averted and compare our outcomes to those of other clinics in the overall cost for similar diagnosis treated. I have examples listed for you below. I would be interested in the insurance companies research on how we have saved them money by managing these cases well by preventing surgeries via performing good quality cost effective care for these patients.

Since we get results for these patients, we get excellent reviews on Yelp and have major surgeons referring to us and looking to us to take care of their patients.

I am writing this letter so that I can explain to you why we are successful. How our methodology has helped save your company money and that you should expect the same from your other providers in this area. The question you should be asking is why some providers patients end up with multiple surgeries and others do not. The number of total visits for such cases should also be considered along with the multiple surgeries rather than the use of procedure code. Please look at the overall picture on how much money is spent on these patients’ surgeries due to complications or secondary problem because they are not treated properly in therapy.

Here are some reviews by patients and surgeons. Goal of patients are to be done ASAP from therapy and get back to their normalcy and to be productive again.

Goal of surgeons is to have a happy patient so that they can provide word of mouth and get others to see them for their medical needs.

Goal of therapist is to get the patient better, prevent complication and make it a quick painful recovery so that they can spread the word around.

Hope this helps in understanding the reasoning and critical thinking it take to provide evidence based case for patients.

Sincerely,

Saba Kamal, OTR, CHT

Director Hands-On-Care