With Operational Snags at AIM Specialty Health Causing Appointments to be Cancelled, Anthem Suspends Pre-Authorizations for PT, OT Care Thru July 31

“Heath care moves fast.  Keep up.”  Those words appear prominently on the website of AIM Specialty Health, a subsidiary of Anthem Blue Cross Blue Shield, and a provider of utilization management services, better known as the “pre-authorization” that medical providers require before agreeing to see patients with insurance coverage.

It is quite apparent now that in the first days of this month, as it was to take over providing those services for Anthem in Connecticut, AIM did not come close to keeping up.

Connecticut residents insured by Anthem utilizing the physical therapy services of Hartford Healthcare, among the state’s largest health care organizations, found that previously routine prior authorizations were impossible to obtain.  Office personal at Hartford Healthcare locations across the state – and perhaps other physical therapy offices operated by others as well – could not gain access to the AIM system to input patient information in order to obtain the pre-authorization required by Anthem before an insured patient could see a physical therapist. 

The result:  physical therapy appointments were cancelled – as many as 6 or 7 a day in some locations – with uncertainty as to when the communication challenges might be resolved, and physical therapy services could be resumed, or begun, for those patients.

Anthem switched its preauthorization process to AIM in Connecticut as of July 1. By July 3, with complaints increasing, both Hartford Healthcare and Anthem determined that the situation was untenable. 

Hartford Healthcare, responding to an inquiry from CT by the Numbers, indicated that “in order to avoid disruption to our patients, Hartford HealthCare continues to provide care to these individuals as Anthem works to resolve the issues.”  In a statement, Hartford Healthcare noted that they were “in contact with Anthem, and we are aware that Anthem is experiencing technical issues with its electronic system for verifying coverage for patients needing physical, speech or occupational therapy.”

Anthem did not respond to a request for comment, but at least some Anthem policy holders were told on Wednesday - with the July 4 holiday weekend just hours away - that Anthem had decided to suspend the pre-authorization requirement for PT and OT services for the remainder of July.  No prior authorization would be needed, individuals were told, because AIM, the provider of those services, “is not able to help us.”  As of July 17, services scheduled to be delivered on or after August 1 would again require prior authorization, patients were told. 

A statement was posted on the Anthem Provider Communications website in at least the states of Nevada, Indiana, Wisconsin, Ohio, Maine and Connecticut, dated July 3:

“Due to recent group membership, provider status, and system issues experienced by Anthem and AIM, the program [which was to begin on July 1] will now be implemented on August 1, 2019.  Effective until July 31st, for requests in progress and for new requests, coverage for Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) visits will not require a prior authorization.”  The statement also indicated that “AIM will manage PT, OT and ST medical necessity reviews and will require pre-certification for all outpatient facility and office-based rehabilitative and habilitative services following the initial evaluation.”

The Anthem “update” to providers indicates that “AIM will begin accepting pre-certification requests on July 17, 2019 for dates of service on and after August 1, 2019.  Ordering and servicing providers may begin contacting AIM beginning June 17 for review.”  Presumably, by “June” they meant “July.”

Anthem was to begin migrating to a new “utilization management” vendor, to be provided by its subsidiary, AIM Specialty Health, in five states – California, New York, Indiana, Wisconsin and Louisiana – earlier this year, according to published reports.  Some – if not all – of those states saw the implementation date pushed back to later in the spring or summer.  In New England, July 1 was to be day one for the changeover to occur in Connecticut, New Hampshire and Maine.

It was also the first day in Nevada. A memorandum in that state, send to providers in April, outlined a transition of medical necessity review of rehabilitative (restoring function) and habilitative (enhancing function) services for fully insured members to AIM Specialty Health (AIM).  The heading of the memo included a prominent misspelling, “CHANGE NOTIFICATION TO NEW AIM REHABILITAION PROGRAM.”

An April memo to Connecticut providers indicated that “AIM will begin accepting pre-service clinical review requests on June 17, 2019 for dates of service on and after July 1, 2019.”  In some instances, difficulties with the AIM system became apparent to some providers when the system could not be accessed in the weeks prior to July 1 for physical therapy appointments attempting to be scheduled for after that date.  The arrival of the July 1 start date, it quickly became apparent, did not alleviate the difficulties. 

At least one customer service representative at AIM, contacted early Wednesday by a Connecticut Anthem-insured patient seeking PT services, shared that there was considerably disarray at AIM, acknowledging that the system was not doing what it was designed to do, and that it appeared incapable of providing the pre-authorizations needed. One described the chaotic scene as resembling “chickens with our heads cut off.”

The AIM Rehabilitation Provider Portal access page now indicates that “Due to recent group membership, provider status, and system issues experienced by Anthem and AIM, the July 1st implementation of the AIM Rehabilitative program for Anthem’s commercial membership is temporarily delayed.” AIM has not responded to a request for comment from CT by the Numbers.  AIM Specialty Health, according to its website, “provides clinical solutions that drive appropriate, safe and affordable care. Serving more than 50 million members across 50 states, D.C., and US territories.”

The July 3 Anthem “update” to providers also extends an invitation for providers “to take advantage of an informational webinar that will introduce you to the Rehabilitative Program and the robust capabilities of the AIM ProviderPortal.”  Webinars to instruct providers on how to access AIM’s ProviderPortal, an online tool used to request AIM clinical review, are scheduled for July 9, July 29 and August 15.

Anthem’s California Provider Communications website also includes the new announcement of the delay in AIM authorizations until August 1, although that state’s switchover to AIM was announced in April and scheduled to become effective on May 1.    

The website PT in Motion pointed out earlier this year that in addition to physical therapy, “the new UM system also includes occupational therapy and speech-language-hearing services, and applies to any outpatient place of service, including both on- and off-campus hospital facilities. Anthem BCBS will require that the new UM be applied for patients with all diagnoses for which treatment is delivered in the outpatient setting.”

It is apparently not the first time that Anthem and AIM experienced bumps in the road.  Two summers ago, media reports indicate there were “difficulties in working with the new Anthem/AIM Specialty Health prior-authorization program for genetic tests.”