Third Party Reimbursement

Insurance Recognition and Athletic Training in Wisconsin

August, 2019

Introduction

The Wisconsin Athletic Trainers’ Association, Inc. (WATA) focuses its advocacy efforts specific to insurance reimbursement upon the transparent and autonomous delivery of physical medicine and rehabilitation services by athletic trainers.  

In accordance with this, the WATA is resourcing advocacy efforts that are in alignment with CMS policy and processes. The WATA believes that this philosophy is in the best interest of athletic training from a strategic, regulatory, and compliance perspective to align with CMS guidelines. It is the goal of the WATA to help secure recognition and reimbursement for athletic training services consistent with other allied health providers when delivering care that is medically necessary as defined by CMS.

Additionally, the WATA asserts that athletic trainers must function under their scope of practice at all times when billing an insurance provider for services that they render.

Background

 What is a Licensed Athletic Trainer and what is their scope of practice in Wisconsin?

  • Athletic trainers are healthcare professionals who collaborate with physicians to provide preventive services, emergency care, clinical diagnosis, therapeutic intervention and rehabilitation of injuries and medical conditions
  • Students pursuing certification as an athletic trainer must earn a degree from an accredited athletic training curriculum and pass the Board of Certification Exam
    • By 2022, all accredited programs will be required to result in a Master’s degree
  • Wisconsin statute 448.95 outlines the requirements for licensure as an athletic trainer within the state of Wisconsin, with 448.956 detailing the scope of practice within the state
  • The statue indicated above defines “athletic training” as including the following:
    • Preventing, recognizing and evaluating injuries or illnesses sustained while participating in vigorous physical activity
    • Rehabilitating and physically reconditioning injuries or illnesses sustained while participating in vigorous physical activity
    • Rehabilitating and physically reconditioning injuries or illnesses that impede or prevent an individual from returning to participation in vigorous physical activity, if the individual recently participated in, and intends to return to participation in, physical activity
  • Line 1M of the Practice Requirements specifies that a licensee may provide athletic training services to a patient in an outpatient rehabilitation setting with a written referral from a list of specified providers that include MD’s, DO’s, DC’s, DPM’s, PA’s, NP’s, PT’s, and DDS providers.
  • Currently in Wisconsin, LATs practice in a variety of settings including professional, collegiate, high school and youth athletics, physician practices, outpatient rehabilitation clinics, and occupational health clinics

 

Are LATs nationally recognized by other healthcare professions?

  •  The American Medical Association (AMA) formally recognizes athletic trainers as allied healthcare professionals and encouraged the use of athletic trainers in every school that mounts a sports program
    • Additionally, the AMA Current Procedural Terminology 2017 Professional Edition code book includes specific Athletic Training Evaluation and Re-Evaluation codes 97169 through 97172
  •  In 2015, the American Academy of Pediatrics (AAP) introduced a resolution requesting support from the AMA to place athletic trainers in all secondary schools
  •  The U.S. Centers for Medicare & Medicaid Services (CMS) provides a discrete National Provider Identifier taxonomy for athletic trainers as part of the National Plan and Provider Enumeration System
  •  Athletic trainers are eligible for credentialing through the Coalition for Affordable Quality Healthcare (CAQH)

 

Do LATs in Wisconsin currently bill Third Party Payers for their services?

  •  As of January 1, 2019 at least 45 LATs representing 15 different employers have successfully billed and received reimbursement from commercial payers.
  •  Athletic trainers have successfully sought reimbursement from at least 19 different commercial payers and 36 worker’s compensation payers in Wisconsin – A full list of these payers is provided in Addendum A
  •  In recent developments, Anthem Blue Cross Blue Shield of Wisconsin, WPS, Arise, and Arise Aspirus have joined other payors in recognizing and reimbursing for athletic training services as on January 1, 2018.
  • The current validated list of payors that recognize athletic trainers follows below.

 

Current Payor Recognition in Wisconsin

August, 2019

Commercial Recognition: Not on Plan Exclusions (12)
Anthem Blue Cross and Blue Shield of Wisconsin
Arise
Arise Aspirus
Aurora BayCare: Self Insured
Dean Health Plan     
FortCare Cerner: Self Insured
Mercy Health Plan
Prevea 360: Self Insured
Sysco: Self Insured
Quartz Health Plan
  • Unity
  • Gundersen
  • Physicians Plus      
WPS

 

Commercial Recognition: Prior Authorization Required (9)
Cigna
Group Health Cooperative
Health Partners
Aetna
Humana
Medica
Network
United
WEA Trust

 

Workers Compensation (36)
Acuity
Aegis
AIG
America WC
Amtrust North America
Argent
Berkley Agri-Business
Broadspire
Chubb
CBCS
CCI, Columbia County
Cincinnati Insurance
CNA Claims Plus
Corvel
Frankenmuth Mutual
Gallager Bassett
Heartland
Horizon Management Group
Liberty Mutual
Pekin Insurance
Preferred
Secura
Sedgwick
Sentry
Society Insurance
State of Wisconsin
Travelers Indemnity
Travelers Property
Tyson
United Heartland
United WI
Wausau
West Bend Mutual
Western National WC
WI State Historical Society
Zurich American

 

Current Known Employers in Wisconsin

Agnesian Healthcare
Aurora BayCare
Aurora Sheboygan
Baldwin Area Medical Center
Columbus Community Hospital
Crossing Rivers Health
Divine Savior Healthcare
Fort HealthCare
Grant Regional Health Center
Mercy Health System
Prevea Health System
Ripon Medical Center
St. Clare Hospital
Upland Hills Health
UW Hospital and Clinics
Wausau Sport and Spine