Increasing Reimbursement for PT, OT, and SLP Professions: An Interview with Candice Mullendore, OT

I'm sincere when I talk. All right, everybody, welcome to our town hall meeting for PTOT slp. We're so excited to have you guys here. We have a very special opportunity to meet together as a group of professionals. And. And we have a wonderful guest today. We have Candace Mullendor. Everybody, put your hands together. You're on the call. I love it. Candice, thank you so much for being here.

Thanks. Sorry, my dog all decided, of course, decided to make major noises. We started, so I had to take her toy away.

Anyway.

Well, you were shoveling dinner in as you were jumping on the call, so I just appreciate the fact that you're here and you're willing to share with us all that you've done. So I'll give a little background on. On her so that she can wrap those things up. So she's an OT that's been in business for over 26 or she's been in OT for over 26 years, but for the last 15 years, she's been an owner of the largest pediatric therapy clinic in Nebraska.

What? That's so cool.

It's called Pediatric Therapy Center. And so they do OTPT and speech, and they have an average of 57,000 visits per year. Guys. So this is a. This isn't just a, you know, a medical professional. This is an entrepreneurial entrepreneur on steroids who's done incredible things. But the reason she's on this call isn't just because she's accomplished so much professionally. It's because she had. She has done so much to help move the needle around. Reimbursement and see. Candace, I just will say before I go into your bio any further, you and Seth and others are the reason we even have these meetings, because it confirms my belief that only entrepreneurs are going to be the ones who are going to save our profession. The rehab. The rehab profession as we know it. You know, again, I don't want to get on a side tangent, but, like, look what you've done. You've accomplished something so significant in your professional world, and you also somehow made time, probably shoving food in as you went to start Advocacy, an advocacy advocacy group, which I could barely pronounce. So she started this six years ago when she was managing care for Medicaid in Nebraska. And so here's what. Here's what their mission is. Number one, to reduce administrative burden to providers.

That alone, the administrative burden that we go through is.

It's insane. And we just take it, you know, healthcare providers, this administrative burden, we, I think a lot of people coming out of school, believe that's just how it is and that there's a reason for it, even if I don't understand it. But there, and there is a reason make it hard for us to get paid. That's the only reason. So number two, her. The group's purpose is to maximize reimbursement for providers, which is awesome. And then number three, ensure patients have good access to care. So here's what they've done in the last six years, guys, they've passed three laws. They've passed three laws. Think about that. Anyway, healthcare providers getting together, they're actually making laws happen. They've achieved 12 visits without prior authorization for Medicare, Medicaid, MCOs and many other things. So as a result, you know, she has done a lot of presents, presentations on this and helping people understand how they did this. And the reason she's here is to share some of her wisdom in terms. I want her to talk about the journey of creating this advocacy group to begin with and then her thoughts about moving forward. Because as you guys know, as we've had some amazing people on these calls historically, there's a real idea that we are starting to have that we need to start this on a national level. And so every time we meet we're taking a step closer to that, like what can we do in our local states, maybe connected on a national movement to start making major change. So Candace, thank you for being here. Did I miss anything in the introduction?

That's the gist of it. And I'm very humble. I don't like a lot of attention. So like, that's great.

Well, and she's humble. Everybody put your hands together for her. Humility. I'm kidding. Yeah, you're very humble for sure.

Yeah. Before. Well, one of the things I was going to share with you guys just to start with, which is not part of my presentation, but I just got this email from Asha today which I thought was really interesting.

And they did a, they got a, a survey of 700 audiologists and speech language pathologists about reimbursement and a lot of other things. And in of those 700.

And they were across home health, skilled nursing, inpatient, outpatient hospitals, private practices and physicians. They 47% of them had prior authorization denials, 46% of them had Medicare payment reductions, 43% of them had commercial plan reductions.

27% had post payment audit and denial, 26% had cuts to Medicaid payment rates.

And then 16% of them had the application of MPPR by a state Medicaid and. Or private insurer. So.

I thought that was pretty telling when it arrived in my box today because that's basically why we do what we do in Nebraska. And I mean. And I mean, we've talked on this call so much about we're in such a strange industry where we've just gotten cuts every year for years, and there's no other medical professional that is getting that and. Or stands for it. So I'm here in Nebraska, no longer standing for it. We're done. We're taking on the Goliaths of the world.

So just to kind of give you guys a brief history is Medicaid managed care came to Nebraska six years ago, and as one can imagine, it was a hot mess of all things.

Any state change. And we had a bunch of meetings with our DHHS leadership and it resulted in kind of weekly meetings where each Medicaid MCO had to be in the hot seat at these meetings. And we would all bring our complaints and they went on this list and they had to respond to us in every meeting. And thankfully our DJ just leadership was really supportive in that situation. So this is how it. It formed just through natural progression because there were three or four of us that were always at these meetings. We are therapy people. And we were like, why? Why? We all have the same problem. Why don't we just start doing this as a group? And interestingly, two of the people are actually competitors, which I love that they were like, yeah, you know, we're competitors, but let's do it because we're all in this together. So a year into the Medicaid MCOs, we decided to form an actual group and then start requiring or asking nicely, whichever way you want to look at it, the Medicaid MCOs and our DHHS leadership to start to meet with us because there's power in numbers. And the other thing we did in that is we got our state associations to support us and be behind us. So I represent the OT association and the Speech association because I'm on both of the legislative Reimbursement committees. PT won't let me on theirs, otherwise I would be on it. And then our other representative is a speech therapist and another OT and a pt. And so we had our state association behind us, which, you know, for whatever reason, it's fine. If they get a letter from us on our State association letterhead, great. They pay attention to it more than they would if it's just from Canada. So that's fine. I mean, that was our strategy, though, was to pull in Our associations, because they truly represent everybody across Nebraska, if you belong. And, and we wanted to be able to, you know, do it just for not only our patients, but for everybody in our state because it's, it's B.S. what's going on in the rehab world. So, so we just decided to form that group. We had no idea what we're doing. We just said we're going to do it. And one of the key strategies that I always like to make sure that I share is. And we have lobbyists for each of our groups. And the PT and the speech therapists shared a lobbyist. OT had a different lobbyist. And so one really successful way to move forward our stuff was we all now share the same lobbyist. So we decided to pool our money, pool our resources, and use the same lobbyists because we rarely are having problems with scope of practice with each other. Like, we're all in this together. There's no reason why we can't pool all our resources for that. And so that was really key. It was about two or three years into our group and we said, look, let's do this. And that's when we sat down with our strategy or our lobbyists and came out with like a long term strategy. Like, what do we want to attack first? What's our biggest priority and, you know, what are our goals and where are we going to go from here? And that was really key for us achieving success in the legislative realm. And I know that's not always possible in every state, but it is something I encourage people to look at is collaborating with each state association and as well as, you know, trying to get the same lobbyist. So. Michelle, are you asking a question?

Yeah, I was asking. I was just. I think Seth does the same thing. I don't know. You have the same lobbyist. Is that just for PT or does that include speech and OT as well?

We do just PT, but it's with our private practice group and the PT association.

So. But it's just, it's two groups, but it's all PT. RehabNet. RehabNet actually represents PTOT and speech though.

Okay. Okay.

So similar.

Okay, okay.

Sorry to interrupt.

No, you're fine.

So we then established what our mission was, where we wanted to go. And so our first thing that we wanted to do was our Medicaid MCOs when they, one of them decided that they were going to make a major policy change. It was UnitedHealthcare, and they implemented it with very little notice. And it was going to require a layer of administrative burden that was Ridiculous. So instead of just trying to get an authorization in place, the doctor would have to put in the authorization, you would have to do the evaluation, you would have to send the evaluation back to the doctor for their approval. Then the doctor would have to put in a second authorization. I mean, it was just layers and layers of administrative burden. And they gave us, I mean it was very little notice with very little training. So we decided that administrative burden was what we were going to try and tackle first. And you know, that doesn't involve a lot of money either out of the state budget. So strategically our lobbyist was like, hey, this is, you know, we're not asking the state to spend very much money, so let's do this. And so we pass our law that every Medicaid MCO has to give us 60 days notice in writing, snail mail in a colored envelope of any major policy change. And Kentucky had actually passed this a couple years before. They called it their orange envelope law. And so we modeled it after Kentucky and they have to do that now. They have already violated that. And we just report them to DHHS and then they get in trouble. And I don't think their intent is ill. It's just, you know, somebody's like, well, we're going to do.

They don't care and they're not used to us fighting it.

Yeah. So they're like, well, whoops, you know. And so we have called them out on that. So that was really our first thing was like, you need to let us know. Because the training behind this was ridiculous and none of us know what's going on. I mean, we were training the physicians offices on what they had to do and that was not fair. So then we, you know, we're like, all right, we got the legislative's ear and we decided we were going to take on MPPR because why not go big or go home? So we.

In the process of doing the 60 day notice, one of the things that I really want to make sure I touch on with you guys is it's all about relationship building. And so we spent a lot of time with the chair of the DHHS helping her understand what we do. We spend a lot of time with the HHS committee members making them understand what we do and how it.

Could you just, could you go through those abbreviations again real quick? Those acronyms? Hhs. Could you say that one more time like with.

Yeah, DHHS is our Department of Health and Service Human Services. Okay. But we have a DHHS legislative committee. So they oversee our Department of Health and Human services to a point. And so the DHHS Legislative committee is who we really targeted because we knew we needed their support for our bills because we were going to run the bills through their committee. I should back up and explain that Nebraska is also the only state that has a unicam rule, so. Yeah.

What's that?

I don't know what that is. I'm not saying what like I'm shocked. I'm saying what like, what do you mean?

Oh, okay. So you know, like in. We have our state, our, Our House and our.

Senate.

Yeah.

Nationally, a lot of states have that as well. So if you pass the bill in one government entity, you have to then get it passed in the second entity. We don't have to do that. We have one.

Oh, that is different than I thought. I thought everyone had to do the two House, you know.

No. So we're. It's beneficial to us because we only have one. So it does work in our favor.

And what's that called?

Unicameral in the camera. Yeah.

So we made sure that we were starting to establish relationships of all the members of our legislative committee because we wanted them to understand what was going on, what the burden was, you know, all the things that we needed to know. And we also then made sure that a constituent that lived in their, their area that might be impacted by all this administrative burden and reimbursement cuts met with them. So we did a little bit of grassroots through our state associations that, okay, who's in this district, who's in that district? Like, who can we send to meet with them? So there was a lot of just relationship building in general with the legislators so that they could understand all, everything that was happening. And we always brought it back to truly, it's patient care. Like, we're limiting access to patient care because we can't get our administrative, you know, burden reduced. We're limiting access to patient care because you're going to have small practices closing because they can't get paid. You know, we're limiting access to care for all the reasons because quite honestly, that's what the legislators want to know about. It's their constituents. And then what is this going to cost the state? So we focus a lot on that with them. So we then decided, like I said, we're going to take on mppr. So if everybody, nobody knows what this is. I know you all do, but it's multiple payment procedure reduction. It's a flawed system. I could explain it to you the easiest way to explain it to everybody. That's not on the call. Is that if you, it reduces the amount of money that you get via reimbursement. I mean, that's really what you need to know. So if you bill multiple.

Thank you for saying it so clean. That's great.

Yeah. Well, I mean, that's what it is. It cuts our reimbursement. But if you bill multiple codes, what they'll do is they'll take a percentage off of each code that you bill. And I mean, it's really complicated trying explain without a lot of visuals, but if you Google it, you'll get a very long explanation of it. But it reduces your cost. And it was designed in the past for like radiologists and anesthesiologists when they were doing some.

If you went in for a procedure and you. They tried to charge you for like two surgical, you know, suites or something. They. What it was designed for was to really limit that in the physician world. But they decided to apply it to therapy because why not?

So then we decided to take on mppr and.

I'm still amazed that we got that bill passed with no, with zero. No votes.

What?

Not a single one? Yeah.

So everyone was in agreement, like, this is clearly a smart thing to do. What, what, what, what, what, what surprises you about that?

Well, I mean, does anything ever get zero, no votes? I feel like there's always some kind of. But the reason why it surprises us is because, well, what we pointed out to them is like, hey, you, the legislators, you make our fee schedule, right? You say we're going to get. I'm just going to say 25 a unit. Okay. But now these, these insurers are saying, well, I'm not going to pay you $25 a unit. I'm going to pay 25 for the first one, and then I'm going to pay a 23 for the second one and 23 for the second. So they're basically reducing the fee schedule. So that's the way we explain to legislators is they're taking the money that you allocated and they're giving us less and they're putting the rest in their pocket.

And so what did they. And so for me, I just wonder, like, how much do you think. This is kind of more of a macro question, Candace, but, like, how much do you think the current situation we're in has to do with the fact that we just don't say anything? Because what I'm hearing from you is with organization and first time effort, you're hitting some pretty big home runs.

Yeah, we are. And you Know, and a lot of my talks is interesting because.

A lot of people have expressed to me the reason why they don't say anything is because they live in fear of the root. You know, the insurers, what are the repercussions going to be? Like, you know, it's just me, you know, what if they take away my contract? What if they do this? Well, I mean, I totally get it. Like, they're Goliaths. We're, you know, little Davids. And I think people need to a get rid of that fear and be like, no, first of all, nobody should be able to hold that over your head. Second of all, I think people, and I don't, I don't want to say this is a global statement, but I think people are letting others devalue what we do. And I, I call BS on that. Like, who. Why do the insurance companies get to say, well, you're actually not worth $25 a unit. We're going to make you worth 23. Like that. Just. I just. We need to stand up for ourselves, not only as a profession, but for our patients. Because if we continue to have cuts and cuts and cuts, our patients aren't going to have access to care. I mean, it's, it's just what's going to happen. And when we spoke at AOTA last month, that's basically what we told a lot of people in the audience is we said we have to fight for our profession or our profession is going to fundamentally continue to change. And I don't know if it's going to be here in 30 years. I mean, that sounds really.

No, I'm in the same page with you, And I think 30 is being generous.

Okay. I mean, I, I just, I worry about our profession as a whole.

Yeah. I think the other thing you said there too, I think this is really important is to remember, is that when you say our profession, we're talking all rehabilitative services.

Yeah.

And I think even, even I, as I started this journey, you came on the first call and I'm like, why didn't I start promoting this to OT and SLPs? I think we get kind of in our lane already. It takes a bigger vision. Like, you've always had an understanding the impact of this thing, but without a doubt, all three of us are tied to the same, to the same thing. Our future is, is inherently interwoven.

Yeah, absolutely. And we're pushing all three national organizations, which I'll talk about later, about what we're trying to push them to do.

So we convinced Everybody that NPPR was, you know, wrong, and they all agree with us. And I. I don't know how we got no votes. I mean, I guess we clearly made our case and helped them understand why this was wrong. You know, it's a flawed policy, and they shouldn't be able to apply it in general. I mean, in mppr, just for future reference, when they redid a bunch of the CPT codes, they did 97129, which is a cognitive retraining code that PTs wouldn't necessarily know about. And then 97130. So 97129 is like the first code, and then each additional 15 minutes is 97130. And the RUC decided to apply a smaller reduction to the 97130, recognizing that, you know, there is some duplication of services. And so it's 5%. It's a 5% reduction instead of a 50% reduction, which is what MPPR is. So I don't necessarily Disagree with a 5% reduction. 50% is not right anyway. I could talk about MPPR for hours, but. So then we got a little cocky, quite honestly. We were like, hey, we got no. No votes. Let's go. Let's just keep going. So we put forth a bill, and. And I go back to say, like, none of these bills were put forth without us trying to work with these Medicaid MCOs. Like, that's really key. Like, you know, you want to try and build that relationship. You want to talk to the MCOs, you want to be involved with their leadership. You want to try to come to some sort of a compromising conclusion. And so these bills were always our last resort. You know, like, we. We went to them, and the senators always asked us that, and we're like, yeah, here's all the dates we tried to meet. And, you know, we tried to come up with a compromise. So we decided to take on a bigger administrative burden. That's the prior authorization process. And we.

It's just. It's a flawed system. I mean, I understand why it's put in place because they're trying to manage their costs. But what we really tried to explain to our legislators is you're ultimately impacting patient care. Because if I. I'll just use a total knee. I have a total knee replacement, and I go into PT and they have to ask for an authorization for additional visits. They see me for the treatment or valentreat, and then they're like, okay, I have to get an authorization sometimes. That could take up to two weeks in our system in Nebraska, they had 14 business days to do that. In the meantime, my total knee is doing really awesome without therapy for two weeks. Right. Like, you're like, okay, so who takes on the risk? Does the private practice or the hospital take on the risk and say, well, we're going to see you anyway, hoping that authorization comes through? Or does the patient take on the risk of they might be responsible for the bill if the authorization is denied? Like the insurance companies are putting all the risk on everybody else, or the.

Risk of the patient saying, I can't afford this, so I'm going to stay home for two weeks and just watch some YouTube videos and develop a contraction.

Yeah.

To get manipulated.

Yeah, absolutely. And so they. So we decided we were going to take that on, and there's some research out there, and I'm not going to remember the name of the entity. It'll come to me after the meeting where they had done some research. And I believe the average length of an authorization was 12 visits. So we just grabbed that number. We're like, okay, this is the only research we can find. We're trying to do things evidence based.

And we decided to propose a bill requiring that the MCOs give every OTPT speech 12 visits without prior authorization.

And.

That created a little bit of chaos, which was fine.

So, of course the insurance companies are going to oppose it. And. But what happened was, when we were in the hearing was.

So the behavioral analyst stood up and said, this is great. We support this bill and we want to be on it. The chiropractor stood up and said, this is great. We like this bill, we want to be on it. The licensed mental health professionals stood up and said, we love this bill. We want to be on it. And so all of a sudden we're like, oh, okay, wow. We didn't expect that. And that created a little bit of chaos because.

It wasn't our intention and we really were just trying to represent our entities.

Does that. Doesn't that slow down the effectiveness when you have all of these groups kind of adding on to the bill and it makes it so that when. When they're trying to pass it, they've got all of these different. Like it's a bigger consideration.

Right.

Like they've got.

It can muddy the waters for sure.

But is there a way to tell them no?

Yeah, yeah. So ideally they would have come to us, but you know, the legislation and sometimes you don't know about these hearings until a day in advance. So.

So that created a little bit of chaos because then all of these entities are approaching the. Our senator that sponsors our bills and, you know, talking to her, and we're like, whoa. And so ultimately, the bill did not pass out of committee because it muddied the waters. But what it did do is we. It pushed the needle to make the mcos meet with us and compromise. So in the end, we got 12 business without an authorization. We just don't have a bill behind it. Ah, got it.

Okay.

Yeah. So two of them were on board immediately. The third took some talking to multiple meetings. And I think, you know, one of the. The MCOs that we work with, and I know when I say this, everybody's going to be shocked, but UnitedHealthcare, they are the best MCO for us.

Hold on, let me just kind of just absorb that. I've never heard anyone ever use the following words in the same sentence. United Healthcare and best.

I know.

Unless it's like the best of being the worst. That's amazing that you had a positive.

Our other mco, Nebraska Total Care, they both like. Our relationship with the leadership at UnitedHealthcare is outstanding standing. And we can go to them with anything and say, like, hey, Cassandra, we've got a problem that's global. Can we have a meeting about it? And it happens.

And they. And they listen to us and we don't always agree, and that's okay, but we respect each other and we can have, you know, positive discourse towards solving a problem. And so they were the first to the plate when it came to the. The 12 visits.

They supported it. And so interestingly, we are actually conducting a research study with UnitedHealCare now, our advocacy group on prior authorizations, and we're doing a retrospective review of all of their data with University of Nebraska Lincoln to really try to find what is, what truly is. Our number of authorizations we need, you know, is it 8? Is it 12? Is it 15? What is it? Because the data will tell us. And so they've been the leaders in our state when it comes to some of these, you know, moving, really looking at, critically at what we can do to make sure the data supports our decisions and ultimately, you know, supports our patients. So, yeah, I mean, United Healthcare, they're, they're, they're.

I'm not complaining. I just was surprised, that's all. I'm so excited to hear that. I know everybody elaboration that has potential. And again, I think for me, it's. I'm very mindful of, like, our mindset going into these things, because I think the default human mindset is to just villainize anything that's in our. In our way. And I think for us, we just have to look inward as a. As per. As rehab professionals and say, well, we haven't provided any direction when we haven't. Well, I shouldn't say any. Obviously you have. But historically, we haven't traditionally stood up for ourselves in a way to where, you know, people are just doing their jobs not to, not to justify it, but just, like, take the energy out of it and to be. To put it in the right area of like, yeah, let's take a stand, because look what you've done. You know, it did. It's not like you went up against this and they started blowing up your car. Like, you did this and you got no. No votes the first time. You've got UnitedHealthcare saying, oh, okay, let's work with you on it. I just think the idea of a growth mindset on this is going to be invaluable of recognizing that we could work with some of these people that we think are, I don't know, enemies. Right. Like you said earlier, competitors came together on this thing. So reevaluating what we're fighting against will probably be more useful for us as we organize and fight something because then we're putting the energy in the right place.

Yeah. And we obviously have a growth mindset in Nebraska because we just, you know, we're going to figure this out. Like, we, and we do try to be positive problem solvers. Like, you know, okay, here's our problem. What, what are some potential solutions to this problem rather than just being the completers.

So we, we got our, our 12 visits with no authorizations, which, you know, and ultimately we also try to help them understand that not only does that reduce the burden on providers, it reduces the burden on you, the insurer, and it also decreases your costs because you're not going to have to have all these people, you know, all these people that have to. You have to employ to review all of those. And we're not saying that prior authorization doesn't play a role in what we do. And we do think that at some point, and especially in the PT in the ortho world, you know, after like maybe 10, 12 visits, maybe you do need to have a, you know, look at where this patient is going and are there issues that we need to address? And, you know, are there barriers going on? You know, I'm in pediatric, so ours is more habilitative versus rehabilitative. And, you know, after 12 visits, we also need to do the same. That could be 12 weeks for us, you know, and, okay, where are we going with this patient? What's going on? So we recognize that prior authorization isn't going away, but what can we do to work together to make it less of a burden on both, on all of us?

I love that.

And that's. That's the model we would really like to see across the country, is let's get rid of this prior authorization.

Really, for all insurers.

Well, yeah, and it makes sense because if, you know, we've been fighting forever as a profession, I'm sure across all three of those genres of rehab, that we're looking for direct access. We want people to be able to walk in and be seen and have it be reimbursed. But when there's prior authorization, it kills the whole power of that. When the payer has to, like, require us to get certain steps done administratively, it makes it harder. And that and every barrier just makes it harder for people and you. And we. Everything that we do is about time. We have to get patients in as quickly as possible. And so that's the thing that I do think we should be very vocal about is in our. In our individual efforts, is making it known that, like, yes, you're just trying to save a buck, but in your delays, you're causing significant negative impact on. On the community as a result of that. So, yeah, let's talk about reimbursement, but let's not delay people getting in, like, prior authorization.

Right, right. So since we got that and we started our research study, we decided we're going to take on the big guns and go private and say we want to eliminate MPPR from private insurers, which in the legislative realm is usually frowned upon. They don't like to legislate private entities.

Sure.

And that's fair. But we had been meeting with Blue Crossbow Shield for. Oh, gosh, we've been trying to meet with them for, like, six months because they decided they were going to cut speech reimbursement 25%. They were going to apply MPPR. They were going to make all these cuts. And we just said, this is not feasible. Like, you can't do this. It's not fair. So we decided to put a bill forth. And some of this is strategic. Right. Like, we know that our bills are not always going to get passed, but it does bring people to the table, and they don't like it when the legislators have to call them to the table and say, okay, you need to, you know, have some compromise here. So our road to limit MPPR and private insurers has been a little bit bumpy or a lot bit bumpy. So our senator supports it. And our Health and Human Services, we had a pretty big overturn in election on our committee and so a lot of it has been re educating them. Our chair, who of the Health and Human Services Committee is now the speaker of the House. So we didn't, you know, have his ear. Our senator that supports the bills is still on the committee and she does still sponsor our bills. But the makeup of the committee has changed. So it's, it's been a little bit harder just due to different beliefs from those senators. And we had a hearing and you know, we do all of our, our.

My gosh, why am I blanking testimonials at the hearing? And Blue Cross Blue Shield brings their somebody in to oppose it and that's fine. And you know, the senator, our senator lets us know, she's like, look, we don't really want to legislate and you know this, but what we're going to do is we're going to make sure Blue Cross Blue Shield will come back to the table with you. Because they had stopped meeting with us. They wouldn't meet with us.

Oh man.

And so we said, okay, great. So then that did bring blue cost Blue Shield back to the table. And it's sort of been a.

I'll use the word interesting ride. They are basically told us they're not willing to compromise. They will not eliminate npr.

So, you know, not unexpected, quite honestly, in our realm. But it also gives us.

More information to take it larger to the media if we choose. That's not something we do lightly. And we always make sure we've met with everybody and we've done all the things. But Blue Cross Blue Shield is our largest insurer in our state. And what is already happening is smaller clinics are closing.

So we had, and we have a very large clinic in our state that does like adult, a lot of different adult. They have hospital contracts, they have school contracts and they've been approached, I think she said, by four or five people to ask to be bought out because they can't sustain it, can't sustain their small practice. And so here in Nebraska, you know, we've got two major cities about an hour apart and then everything else is rural. And so when you lose one provider from maybe one county that could be your only provider. We do have counties with only one provider in them. And so it's impacting access to care. So we're kind of in the process of regrouping here a little bit and figuring out where we want to go with this. Our legislator in Nebraska Legislature in Nebraska is sort of in a really stormy part right now. Nothing related to our mppr. Sometimes it's in the national news.

Yeah.

So there's a lot of things stalled. So our, our bill is officially stalled out of committee and I'm not sure if any other bills are going to get past the session. So there's, I don't know if we're going to reintroduce our bill next session. It's just, it's been a very interesting session here in Nebraska and probably other place places. So it's in this holding pattern and we are in the process of trying to continue to work with Blue Cross Blue Shield and figure out like, okay, what are we going to do to, you know, help each other out here? And if necessary, I mean, we do use the media and we have used the media on our other bills in the past to help bring awareness to people who wouldn't otherwise know. We've had patients and their families testify for us in support of our bills. Wow. You know, we, we do reach out to other organizations for support. So, you know, they might write us a letter of support for some of our bills, you know, if they, if they feel like they will. We have had our physicians on our 60 day notice bill, our physicians entity 100% backed us and testified for the bill because they, you know, obviously it was a burden on the physicians as well. So.

You know, we have this small group, the OTPT speech, but we also formed a large group which includes OTPT speech, mental health, pharmacists, physicians, can't remember if behavioral health is on it, Chiropractors.

No, they haven't been in that group. And I don't know why.

There's like 10 or 13 of us. And so that group actually we just work on larger issues. Like we're working with our Department of Health and Human Services on their. We're getting new Medicaid MCOs. And so we work together to try and give them some guidance on, hey, when you're looking at a new, you know, entity to come in to be a managed care provider, I mean, here's some things maybe to consider in the contract. Here's some things.

How do you get these groups together? Like, my whole thing is like, who are these individuals? How many actual individuals are in these groups? How often are you guys meeting, like, what does that look like?

So in my smaller group, there's really, it's the five of us that are the core. But then the presidents of each association usually attend the meetings. So that's what, eight people? And then some of them have executive directors. So maybe there's 10 or 11 of us in a meeting, and then our lobbyist. And so we meet. It depends. We meet depending on where we are in the session. So in the beginning of the session, we might be meeting every week or every couple of weeks to kind of talk about strategy. And then now we're sort of in this holding pattern, so we haven't met. And then we may ramp up again before our next session in the fall and be like, okay, the month before, we might meet every week to figure out what our strategy is. It just. It really depends. Our larger group, we meet, I don't know, maybe every quarter to kind of talk about things. And again, it depends. And that one, I honestly have no idea how it was formed. It just was like, this very natural. It started from us being in all these meetings six years ago, and we were all like, this is ridiculous. Like, we need.

It's kind of like a networking thing. You're there like, hey, what are you doing? I'm here for this. Yeah, that stinks. And then you just start connecting cards. Huh. So who's running these meetings on both ends? Like, is there. Are you, like, welcome? You call everyone to attention? Are you guys, like, what does that look like? Do you have a president? Does it. How is it organized? I don't want to get too in the weeds, but I am curious about, like, how these meetings even look like structurally, what they look like.

Yeah. For. For my smaller group. Um, honestly, it's. Whoever wants a meeting calls a meeting. So, like, I'm actually in the process of calling a meeting and say, like, okay, where are we at? What are we going to do? I'll be honest. Clearly, I'm passionate about this, and I. I'm very organized, so I tend to be the one to be like, okay, before we get off the call, let's schedule the next meeting.

So that. So this is the. So this is a humble person's way of saying, I'm in charge.

That's what you just said.

You're like, I don't want to say.

You know, we have such a fun thing in rehab about, like, being like, yeah, I run it. Clearly you do. Candace, you were coming to this meeting. You were just, like. You just showed up and started creating value. Clearly, you're a leader's leader. I get it. It's.

Well, thank you nothing.

It's nothing to be ashamed of. I think it's amazing actually. And I would hope people are hearing this, feeling inspired by that. That fact. So you run that piece. Do you also call that combined quarterly meeting with all those different.

Yeah, that is organized actually by the behavioral. No, mental health. No, I feel like it's a behavioral. The president of the behavioral association or licensed mental health association. I'm not sure he has like an executive director and she just organizes it so she will like call the meeting and make sure, you know, the people are on the invite and then we might forward the invite, invite other people. So. And kind of just coordinates it all. And I don't know how that started. I think she just like naturally took it over and said, I'm going to do this. And we, we met more before there was a request for a proposal for new MCOs in Nebraska and we were meeting a lot before that, this was last year, to make sure we had the ear of our DHHS leadership to say like, okay, these are the MCOs. This is what we like about them. Like these are things to consider for the contract. And we really have their ear. And I think at this point we have. So we meet with our DHHS leadership maybe twice a year just to talk through things. Or like they called a meeting to ask us about. We actually, I forgot to mention, we passed a law making telehealth permanent for our Medicaid MCOs as well. So we don't have to deal with that whole CMS stuff that's going on right now. Right. And so they called us and said, hey, you know, the public health emergency is ending, but we need to talk through like how this is going to work for OTPD speech. And they, they asked for our advice. So for us that's huge, you know, and that's all built on relationships, really.

Yeah. You know, one of the things that we always promote, this is a big. This is like an entrepreneurial thing, but it bleeds into the truth of like gravity. Right. Like it's a law, is that our network is our net worth. And so when you think about like your journey, how your network with other entrepreneurs in OT and then later PT and SLP and then like how you've networked with the governing bodies and then other industries governing bodies like this natural occurrence, like human nature of networking, if we just put ourselves out there and are willing to take the time, which I think is the biggest struggle that all of us face, it's time, secondary money. Which is my next question for you. By the way. But, like, when we take that time, that network builds, and then it's like the movement just kind of creates on its own. So that kind of leads me into. My next question is, like, how are you funded? How are you paying for the lobbyists? Like, where do you guys ask for donations? Is it coming out of your pocket? Are you, like, what does that look like? So is that too personal to question? I don't even know.

No, no. The funding for our lobbyists comes out of our state associations. Okay.

And then everything else you're doing is just pro. Like, you're just doing it. Volunteer.

I'm not paid. Nobody on. Nobody in any of these meetings is paid.

Okay?

So it's just those of us that are on the legislative and reimbursement committees for our state associations. You know, we do it pro bono, just like anybody else would volunteer for the PTA or, you know, manager of a sports team. And so we just do it. And I think.

When we were able to pool our money and our resources for that lobbyist and that, you know, made a difference, because then we could afford, you know, what we wanted to be able to afford in terms of. In this lobby. She's amazing. So it's just funded. And one of the things we really do help everybody understand is, you know, people are like, why would I join my state association? And we say, because we're doing this. Like, we're doing all these things. And that's why you need to join, because we actually are putting your money to good use. And honestly, I know people, you know, will dog on the national associations a lot, but they have helped us so much in our fight. Apta, Aota, Asha. We can call up our, you know, state representative and be like, hey, we're trying to do this. Get us some data, and they'll shoot it to us. We had Asha in a meeting on the phone with UnitedHealthcare twice. They had, I don't know, leader of regulatory affairs or something in the meeting to participate because we wanted them behind us about something. And so we, you know, I know that it's not cheap. I mean, our state dues are cheap, but, you know, the larger organizations are not cheap. But I promise you, some of that money is doing some good for you as an individual.

Yeah, I love this. And I think what you're defining here for this group in the audience, for me at least, is this idea of, like, I've been in. I've been in a little bit of a conflict with the national organizations. I'm not on the bandwagon of like anger and like they don't do anything. I don't believe that at all. I think there's amazing men and women who are volunteering and stepping into these positions who are changing the industry. But the whole point has been, is that whatever we've been doing isn't working. But what you're saying is that what you created, Candace, and I love that you're promoting these organizations as if they alone are doing it. But it's not them alone, it's them with the additional support that you provided through your advocacy group. Like that's the, that's the interesting combination is realizing that whatever long term solution, national movement we're going to create through doing this, it's going to be in partnership with these individuals and, and like kind of filling in the gaps of what in some ways they just legally can't. You know, there's anti collusion laws and things like that that exist. So we have an opportunity as entrepreneurs to organize and create and almost like be the thing that. So they're not the solution, but they are the fuel. They can provide fuel, education, support to the solution is what you're, is what I'm hearing you say, am I far off?

Yeah. And they ultimately, you know, they may end up being the vehicle for change if we want to get rid of mppr because we got to get CMS to get rid of it.

I see.

You know, and so like in, on a state level we've gotten rid of Medicaid, but we are going to need our national associations behind us if we want to make huge change. Right. And I think us in Nebraska, we finally got the ear of AOTA and APTA and you know, they're lobbyists and, and we actually sat down with them at AOT and APT and we sat down with apta's legal team to talk through a bunch of stuff and, and really, you know, grassroots can have great change. Clearly we're doing it in Nebraska, but Nebraska isn't going to affect national change alone. Like we need the, you know, we need Montana, we need Arizona, we need Arkansas. We need everybody to be going to our national organization saying like hey, this is a problem, we need to tackle this. And, and I, they do great things like they're fighting CMS on this whole telehealth brouhaha that they created in the last week, you know, and, and they really do are, are trying to do things for our profession but I think ultimately we do need to come to them from a multiple grassroots and be like look, we cannot continue to have cuts. We can't. Like, we can't. That needs to be our bottom line. Like what are we gonna do to get 40?

We're messed up. We're really, we're way past the stage of like it. We're gonna be in trouble. We are knees deep in alligators right now.

No, I agree. So I, you know, I think they also are the fuel for us but I think ultimately they're going to have to be the vehicle because CMS is not going to listen to the Candices, the wills, the Michelle's, you know, like they're not, they're going to listen to the bigger guns. And you know, ultimately that's why AOTA and APT and Asha have really good paid lobbyists so they can do that for us.

So.

Well, very useful. So what is your vision moving forward for both this advocacy group? What's your vision for like I don't know, the professions nationally and like what does that look like from your, your very like profound perspective.

So here in Nebraska we're going to continue to figure out this MPPR with private insurers. I'm not sure where that's going to go. We also are going to tackle our Medicaid reimbursement. That's been on our agenda to say like, okay, we, that we can't continue to take cuts in this. It needs to be be, you know, sorry, you know, nobody else takes the cut for this many years. And then oddly for occupational therapy, the ADL code is not paid for us in the. I know, I know, don't get me started. I know. It's so wrong on so many levels. And so, and that's something obviously our PT and speech therapist would support us on. So our, we want to get the ADL code on our fee schedule. It's not on our fee schedule. We don't know why, it's crazy. But that will be a much bigger hoop for us to jump through than just like passing a bill. So that's on a state level, that's really what we want to do. And then we're, we're trying to figure out, we've gotten grants in the past to kind of fund going across the state to inform people. We've talked about whether or not we want to do that. But we also are engaging APT and aota. Asha hasn't, I don't know, we haven't had as much engagement from them yet and really starting to figure out what are we going to do on a national level. So we have discussions, we're on committees with both of apt, PTA and AOTA to discuss like what are we going to do about this? So we're kind of actually making them listen to us. Maybe, or maybe they're tired of listening to us. I don't know. I don't really care as long as they're listening. And then I mean ultimately nationally we want MPPR as it is gone. If you want to give us 5% reduction, fine, whatever. Like I feel like that's going to be a compromise because that's what the rec, you know, did with the 97129 and 97130. But it's flawed. It's not a, it's not a fair policy to apply to us. That would be our first thing. We're really hoping with this research study with UnitedHealthcare that we're going to get some good data that we can, you know, start to publish and, and that will then guide other insurers like oh hey, we only, you know, adult orthopt averages nine visits, you know, and then they discharge the patient. So why do we even do a prior auth? Like what's the point? And so maybe giving us some, some real good data that we can make good, informed evidence based decisions about.

So that's sort of our vision. It's now I think through it, it's pretty much where we're going to go from here.

It's beautiful and inspiring for me. I think my question and every one of these meetings has always come back, always comes back to this. How are we going to organize this on a national level? Like I said that with Seth and then Kristen and now you. I just, I just feel like there's, and maybe you can't, maybe it's impossible to work. I'm never going to say that it's not impossible, but maybe the, the steps towards growth is organizing things on a state by state level. But you know, I, I would really like after this meeting for, for us to get together. I've emailed and started a couple months ago. I said let's get together and have like a private meeting. I really would like to do that. And, and Noreen and Earl and you know, you guys are invited but I just think, and I would just like have a discussion of like a strategy session of like okay, so let's, let's pretend like we were not limited in any way that we were powerful enough to create a movement nationally. What would that look like based off of the foundation that you guys have laid in your individual states? What does that need to look like? So when I'm playing that sandbox of idea impossibility. Because what you have done is so amazing. And it's like, how do we get the message out there? This meeting isn't nearly enough. I email my limited email group about it, and as much as I love the people in this group, it's. It's a very. It's not enough. We need to get. We need to grow. We need. We want to have as many people. I want this to be almost synonymous with the national statewide organizations and our national organizations, because this is more of the movement. Like you said, maybe they do become the vehicle, but at least the movement here becomes the initial vehicle. And you started it well before it even occurred to me, right in your own state, just like Seth did and Kristen and. And so, yeah, I don't know, like, what are your thoughts? Just maybe we can. You know, it's about. We're almost out of time, so let's do this. Let's get offline. We'll talk more about, like, ideas for creation. But I would like to give you a minute to give a final thought on, like, your personal.

Like, call to, like, drive to want to inspire people to. To take a stand. Like, just kind of talk a little bit about that. And then from there, we'll. We'll open it up for a few Q and A, and then we'll wrap up.

So, I mean, I think on my personal call, you know, when we spoke at aot, there were a couple of students in the audience. And, you know, they don't. They don't know. I mean, you don't know what you don't know. And they really don't know much about the profession and when they're beginning. But one of the things we really tried to drive home to everybody in the audience was.

We'Re at risk, you know, where our professions are at a risk. I feel like we're really a turning point here, that we need to start to fight. And. And I think that each, every single one of us renew grad. We've been out 27 years, 40 years, whatever. Like, we are worth it. Like, you should be paying us what you're paying us. You should be paying us more than what you're paying us. But, you know, we're worth it. Like, we're the experts in our profession. Just like, you know, an ENT is the expert in his profession, and, you know, a pediatrician is the expert in his.

Profession. Just because we don't wear a white coat doesn't mean we should be valued the same way. Sorry I said it. Like, I, I think that we are worth more than we are ever paid at this point. And, and we need to start to respect that and fight for it. I mean, that's my calling. You know, I have a fairly large clinic with 30 or so employees. I mean, that's small for like some of the bigger adult ortho ones, but for pediatrics it's fairly large. And, and it makes me mad. Like I want to be able to continue to give my staff raises, I want to pay them what they're worth. I want to do all the things, but in the end, there's only so much I can cut. And if I'm not getting increasing reimbursement, you know, we're going to reach a turning point at some point. And so that's why I fight. I mean, I fight for my staff, I fight for my patients, I fight for the providers, I fight for the students that are in school that have no idea what they're going to face. You know, I mean, I've lived through a lot in my years from all the sniff changes in the late 90s. And you know, it's like the cycle for all of us, but I think we all have to stand up and fight and it doesn't have to be on the level I do it. You can write a letter to CMS through a form letter the APTA send. You do it. It can take you five minutes. I mean, you know, you don't have to be doing all the things that we are doing, but you can make change through little things. So I don't know, I could probably go on forever about what, what I think you should do, but I think.

You'Re going to, I think you're going to come back on and we're going to do another one of these because I feel like we're barely scratching the surface in the world of Candice. And I just want to thank you so much or your constant support of this thing that has evolved without even really knowing initially what it is. Every time I'm with someone like you, there's this like, almost like this vision that starts to appear of something better and I don't know, it supersedes everything else we're doing individually. Our individual. We get so sucked into the minutiae of our daily company, in the work and all that. We're not that when we talk about these things, I feel empowered. I feel like this, this realization of a possibility of something bigger out there. So thank you Candace, for taking time to be with us.

I mean what we're doing is very similar to what Seth did in, you know, Arkansas. Like trying to bring together a group of people for the betterment of everybody.

Yeah, well. And at the end of the day when we take the time to network, our collective net worth starts to scale, doesn't it? Like yeah, you have definitely provided value with that. So guys, I'll turn the time over to you. Does anyone have any questions for Ms. Candace before we wrap up? Comments, jokes, everything that's appropriate. I have to say that yourself.

Candice, thank you. Oh, go ahead.

Oh no, go ahead.

Okay. Candace, I want to thank you. It was really great listening to you. One of our house representatives in my state was a physical therapist, owned a practice in the northeast part of the state, sold the practice after he became house replacement and just the other day.

Got a text from him with the president of our association on the text and our state legislative committee.

That I had my labor and health committee agreed to push forward three of my bill agendas concerning white bagging, which I'm not sure what that is, pre authorization law and insurance. Look back, it was interesting that the insurance companies flew in national people, attorneys and pharmacists from New York and Washington D.C. to fight against my ideas.

He said it was a fun two days. So like they're not taking this lightly that we've had enough and it's having groups like you that just inspire the other state. The whole time you were talking, I've been texting with my house rep and our president. I'm like, you gotta contact this woman. This is what they're doing. So I thank you.

No, thank you. Yeah, I mean if it can happen in Nebraska, it can happen anywhere. I mean assess can pull off what he does in Arkansas it can happen anywhere.

We're Wyoming so it's a little smaller.

But yeah, I think that's where it.

Always, I think that's where movement begins though. It's the good hearted people from states like Arkansas, Nebraska and Wyoming. Like it's. This is where those things are. That's the soil these things are grown out of. And man, that's so exciting. And I've got to say Noreen, I was especially grateful that you jumped on today. I didn't know you had such an experience in advocacy fighting as well.

In the past.

I haven't done much recently because of my business, but I was president of wyoming for about 10 years.

Two times.

Oh wow.

10 years total. But I was vice president, president took a break and then president again and held different positions in the state.

Well, that totally solidifies my thought too of this whole thing about like, we have the talent, we've got the, the right mindset for the most part. We have now the group, the entrepreneurial group. We just need the structure in order to do that. And some of you even started doing that. Seth, what was your comment?

I was gonna say, I, I agree with you Will that Candace. Awesome, awesome things you're doing there. I, I mean I'm, I, I will applaud you with that. And there are things that Rehab Net and Arkansas can learn from what you guys are doing up there. And we need to get together. We need to.

Well, I'm going to organize that. Yeah, I'm gonna. If there's an email coming out tomorrow, let's please get on a call. Noreen, do you want to be in that email? You're on, you're on a big like, YouTube video. So you're a lot of pressure to say yes.

Sure. Well, and I think, you know, the thing to, you know, I'm not the only one in my group that really pushes for this. So it's, it's been a very much a group effort. And I almost feel like the nice part of it is then we balance each other. When one of us is irritated, somebody else will take the, you know, helm. And, and so the, the five of us, the core of us, the four or five of us that have really stuck together over the six years. I mean, Mary and Brian and Jessica, who I always present with, the four of us, I don't know. We've just.

As a group, we've been very effective and we're fortunate to have our state association behind us and, and I think, you know, individually it's hard, but if we, like you said, well, after this, if we can come up with a group and a strategy and a, you know, like long term goals and short term goals and we all know how to set those and, and really figure out where we want to go from here. I mean, I think it can be done. It's. It, it won't happen overnight, but it can happen.

Well, I will tell you this. I think I'm, you know, I always believe things happen for a reason. I think Michelle and I's purpose in this is, is we, we can create organizational structure as, as, as one of our greatest talents is truly. And again, we don't have the knowledge, background, experience, or even some of the talents that you guys have. But what we can bring to the table in this in an organizing way is structure. We know, we know how to build things and I think that's where I'm excited about is we don't know how to fill it, but we know how to build the frame. Michelle, what are your thoughts as we, as we wrap up?

Absolutely. I'm excited about the possibilities that this group has and I'm excited to learn and be able to like with the knowledge that you guys bring, like Will was talking about, create a framework on how to get this moving. So that is one of the things that we do bring to the table. You know, a lot of that. Being visionary from Will and now visionary from the you individuals. I really, I really work into the implementation thing. So I'd love to start putting some of this stuff in motion with, with your guys help.

So love it, Michelle. Well guys, thank you so much for your time. Have a great rest of your night. Expect an email tomorrow. And for everyone who's listening in your card, you know, never give up hope, guys. We're there. There's a movement coming and apparently it's coming out of Nebraska, so.

In Arkansas and Wyoming?

Yes. Not just Nebraska, not from Nebraska. Okay guys, have a great night.

Bye.

Bye.

Bye.