Frequently Asked Questions (FAQs) for Physical and Occupational Therapy (PT/OT)
Who is Palladian?
At Palladian, we coordinate and manage care for people who need help from doctors and health care specialists in areas like:
- Physical Therapy
- Occupational Therapy
- Speech Therapy
- Chiropractic Care
- Fitness
- Behavioral Health
Our goal is to help you receive excellent care with a focus on healthy muscles, joints and bones.
What is required to obtain therapy services?
Most health plans require that you obtain a written referral and/or prescription from a qualified provider. "Qualified providers" are defined by state and/or federal law, and may also be specified by your health benefit plan. You should obtain any necessary referrals and/or prescriptions prior to scheduling an appointment for therapy services. If your referral or prescription expires, you may be required to obtain a new one prior to receiving additional therapy services. Once all necessary information has been obtained, your treating therapist submits an appropriate claim for approval and/or payment of therapy services.
Why is my health insurer using Palladian now?
When you need to see one or more specialists, Palladian can help by coordinating care for you. By using our services, your health insurer is making sure that you get excellent care through our large network of doctors and specialists.
What therapy services are covered?
Your particular health benefit plan defines the type of physical and occupational therapy services covered, limited, and/or excluded. You are encouraged to consult your specific benefit plan and Member Handbook to determine whether any specific limitations or exclusions for a particular service apply. Please note that although a service or supply is authorized,certified, or found to be medically necessary, this does not mean that the service or supply will automatically be paid for or covered.
In general, what conditions or services do NOT qualify for therapy coverage?
- Services obtained without a valid referral or prescription
- Services that are not medically necessary
- Services outside the practitioner's scope of practice
- Services that have not been proven effective
- Conditions or diseases where therapy is contraindicated
- Investigational and /or experimental services or treatment
- Maintenance, Preventative or Wellness Care
Why do I have to fill out forms to get treatment?
The forms help us learn about you and your health, how well you can perform daily tasks, and how pain is affecting your health and your life. We use this information to determine the best treatment plan to help you get well again. It also helps Palladian know whether or not the care you are receiving is helping with your condition.
Who created these forms?
These forms were created by a team of specialists that includes doctors, therapists and other people who treat or study injuries or illness. Some of them work for Palladian and others are part of a group called our "Clinical Advisory Board."You will find a list of these specialists on our website.
What are these forms for?
The forms that you fill out are called "Intake" and "Outcomes" forms.
The"Intake" form helps us learn more about you and your health when you start using Palladian's services. When you fill out this form, the information helps the people treating you to learn more about your health. The form also helps Palladian get you the right care for your condition. The "Outcomes" form helps us share information between health care providers. It includes a system that categorizes the symptoms you have and the level of pain you feel.
There is also a "Treatment" form that your doctor(s) or specialist(s) fills out that includes basic information such as your age and where you live, and a brief evaluation of your condition.
Why do you ask questions like "Have you felt calm and peaceful?"
Having an injury or getting sick can affect many areas of your life. For example, if you hurt your leg, the aches and pains you feel may make you decide that you do not want to go to work or ride a bicycle. Over time, this can make you feel sad or angry or have other feelings that show that your well-being is low because of your pain.
When Palladian manages your care, we ask questions like this because we can help you get the care you need to feel better all over.
Why do you ask questions like"Have you lost a lot of weight without trying?"
You may use Palladian's services for certain reasons, such as to get care for back pain. Sometimes, though, these things can be symptoms of unknown problems. Questions like these help us understand if there may be other serious health concerns,and if the doctor or therapist you go to knows the answers, he or she may be able to find these problems sooner.
If my health plan includes visits for this care, why do I have to fill out these forms?
With treatments like physical therapy and chiropractic care, there are two kinds of services available, called "active treatment" and "maintenance care."
"Active treatment" is medically necessary, which means that you need treatment to recover from your illness or injury. During active treatment, the cost of your care may be covered, in part or in full, by your health insurer. The other kind of care is called "maintenance care." Most health insurers, including Medicaid and Medicare, do not consider maintenance care to be medically necessary and usually do not cover the cost of this kind of care. Filling out these forms helps Palladian and your health insurer know when the care you receive is medically necessary.
How does Palladian decide how many visits I get?
Palladian's team of specialists, called "clinical peer reviewers," use many sources - including the forms you fill out, the information we get from your doctors, medical guidelines and treatment evaluations - to decide what kind of care you need and to create a plan to help you get well.
Who reviews my information?
Our team of health therapists reviews it to decide which services may be best for you. Our reviewers have education, certification and experience in their specialty areas. They also work closely with our medical director and staff doctor when needed.
Do you have licensed therapists on staff?
Yes! Our clinical reviewers include therapists who are licensed and registered to practice physical or occupational therapy. Each has at least five years of experience and has received training by Palladian on our procedures and standards, too. Our clinical reviewers are on hand to talk to doctors or other health care providers during regular business hours. In addition, if an urgent situation arises regarding your treatment, your health care specialist can also reach Palladian's clinical director at any time.
What are their credentials?
Our clinical review team includes four physical therapists with doctoral degrees and an occupational therapist certified in hand therapy. We have four doctors of chiropractic with more than 10 years of experience each. Our medical directors are licensed medical doctors who are board certified in one or more specialties.
What guidelines do they use to review my information?
We use written guidelines based on methods that have resulted in improvement when used to treat patients with similar conditions (called "evidence-based" information). They also follow state, federal and other agency requirements as well as the requirements of your health plan. And because every person is different, we also consider your individual circumstances when we review your information.
You can review and print a copy of our guidelines on our website at www.palladianhealth.com. You can also contact Customer Service to get a copy at no charge.
What can I do if my treatment is denied?
If that happens, you will receive a letter sent through the United States Postal Service mail and a copy will be sent to your provider, too, with detailed information about steps you can take.
For example, your provider can contact our clinical reviewers to discuss the decision. In addition you, someone you choose, or your doctor can ask for an 'appeal' of the denial (a denial is also sometimes called an "Initial Adverse Determination". The request can be made over the phone by calling our customer service department or you can write to request one. Please be sure to read the letter carefully because there are limits to the requests for appeals.
What if I change my doctor or therapist before I use all the visits from the first one?
It is important that we know when you change so that you can receive continued treatment. If you stop seeing a health care provider before you use all the visits, please contact our customer service department right away. That way, we can make sure that your doctor or therapist sends us the needed paperwork to continue your treatment. It helps us to know why you changed, too, if you want to tell us, because we want to make sure that all of our members receive excellent care.
Can I get or continue my treatment without filling out these forms?
Palladian requires these forms because we are working together with your health insurer to make sure you get the safest and best care available. The information helps us understand the services you need, why you need them, and how your treatment is working. By following your progress and sharing the information with your health care provider, we can be sure that you get the care you need.
Who can I talk to about this new process?
You can call our customer service staff Monday through Friday from 8:30 a.m. to 5:00 p.m. If you call when our office is closed,you will hear instructions about how to leave a message, and our staff will return your call within one business day. You will also hear information about what to do if you have an urgent situation that needs immediate attention.
