With the shift to managed reimbursement for manual therapy slated for July, the government has begun building a ‘real-time manual-therapy management system’. Even if patients move among multiple hospitals to receive manual therapy, providers will be able to check the cumulative number of sessions immediately, and if the set number of sessions is exceeded, entry of clinical information for managed-reimbursement claims will be blocked.

According to reporting on the 3rd, the Health Insurance Review and Assessment Service (HIRA) on the 2nd distributed development guidelines for the ‘real-time manual-therapy management system’ to frontline medical institutions and electronic medical record (EMR) billing software vendors. The plan is to aggregate clinical information from individual hospitals to build a real-time monitoring network in time for the rollout of managed reimbursement for manual therapy scheduled for the 1st of next month.

The key tool for managed-reimbursement control is the ‘HIRA e-form (electronic form) agent’, which was also used when Chuna manual therapy was brought under coverage. It is a type of data transmission program linked to the electronic medical record system that hospitals and clinics use to record patient care. It submits to the HIRA system those items from the clinical information entered by providers that are needed for claims review.

Applied to manual therapy as well, the information that hospitals and clinics submit at the ‘time of care’ accumulates in the HIRA system as patient-specific utilization history. As a result, providers will be able to check in real time the number of manual-therapy sessions a patient has received that day, in a week, and in a year.

This will be the same even if a patient moves among multiple hospitals and clinics. For example, if a patient receives manual therapy at Hospital A in the morning and then seeks manual therapy at Hospital B in the afternoon, a warning will appear saying, “Same-day clinical information exists. Manual therapy can be provided only once per day.” A HIRA official said, “Medical institutions can check the cumulative number of times the patient has used it before the visit and inform them whether it exceeds the standard.”

If the set number of sessions is exceeded, entry of clinical information for applying managed reimbursement becomes impossible. According to the guidelines, if more than once per day or twice per week is attempted, entry is blocked immediately. If the annual cumulative total exceeds 15 sessions, entry is allowed only when there are exceptions such as surgery or fractures, and if it exceeds 24 sessions, entry becomes impossible with no exceptions. However, the exact threshold numbers have not yet been finalized. A HIRA official said, “Manual therapy is currently before deliberation and resolution by the Health Insurance Policy Deliberation Committee, so figures may change during the discussion or prior notification process.”

Controls also operate at the billing stage. If a medical institution bills only the cost without transmitting clinical details to the manual-therapy management system, at the computerized review stage it will be classified as a ‘claim not registered in the management system’, and the fee will be reduced or adjusted. The idea is to block so-called ‘manual therapy shopping’ at the source through a ‘double control network’ of pre-registration blocking and post hoc fee reductions.

The new system is expected to be applied in the field immediately as the program takes effect. A HIRA official stated, “We are reviewing a plan to apply the system at the same time as the shift to managed reimbursement for manual therapy.”

However, considerable growing pains are expected before the program takes root in practice. For now, the medical community is pushing back, citing increased administrative burden and infringement on clinical autonomy. In fact, the guidelines stipulate that manual-therapy clinical information must be submitted at the ‘time of care’, not at the ‘billing stage’, and require a warning that “if submission is delayed for reasons attributable to the medical institution and another institution registers first, coverage recognition may not be possible.” Because providers must check the cumulative count for the patient for each manual-therapy visit and register the clinical information immediately, they may face disadvantages in coverage recognition if they do not do so.

Criticism is also mounting that this is a uniform control that ignores patient conditions. A medical community source said, “Patients recover at different speeds and require different numbers of sessions, so mechanically capping the count and shutting the system off harms the clinical autonomy of physicians and the right of patients to receive treatment.”

Specific fees and coverage criteria for managed reimbursement of manual therapy are scheduled to be deliberated and decided on the 4th by the Health Insurance Policy Deliberation Committee.