Engagement with payers is key.

As payers explore ways to cut health care costs and reduce utilization, APTA has seen a surge in the use of programs known as third-party physical medicine and rehabilitation (PM&R) benefit management, or utilization management (UM).

Their increased popularity is due in part to a provision of the Patient Protection and Affordable Care Act (ACA) called the medical loss ratio (MLR), which is intended to limit insurer profit by requiring that a minimum percentage of premium dollars be spent on medical care (as opposed to administrative costs). Under this provision, midsized insurers are required to maintain an 80/20 ratio—meaning that at least 80% of premium dollars must be spent on medical care, and no more than 20% may be spent on administrative costs. Large-group plans must maintain an 85/15 ratio. If an insurer does not achieve the medical-care ratio target, it must pay a penalty in the form of customer rebates.