Navigating advocacy with commercial insurers: What AOTA can (and can’t) do for you

Occupational therapy practitioners (OTPs) are increasingly facing challenges with commercial insurance coverage of occupational therapy services. In response, the American Occupational Therapy Association (AOTA) has expanded its advocacy efforts to ensure that OTPs can deliver essential services without undue administrative or financial barriers. However, OTPs need to be aware of the opportunities and boundaries for AOTA and state associations when engaging with commercial insurers.

AOTA’s Approach to Commercial Insurance Advocacy

AOTA’s policy team’s advocacy spans the federal, state, legislative, and regulatory spaces. This means we work to influence both legislation and the rules governing insurance plans created by state and federal agencies. AOTA staff and member volunteers work to address coverage gaps in commercial insurance, Medicare Advantage, and Medicaid managed care plans, often partnering with state associations to challenge restrictive policies such as limitations on habilitative services or limited CPT^® code selection. AOTA strategy encompasses direct policymaker engagement, submitting comments to federal agencies like the Centers for Medicare & Medicaid Services (CMS) on proposed regulations, and participating in coalitions that advocate for broader access to rehabilitative and habilitative services. Staff also monitor payer trends and emerging issues to proactively address barriers to care. These efforts center on areas where AOTA can meaningfully and appropriately intervene within established legal parameters such as coverage criteria, scope of services, and administrative burden.

Understanding Antitrust Boundaries

It is important to note that associations must tread carefully. The most common inquiry to AOTA about insurance companies is relative to reimbursement rates; however, AOTA (and other provider associations) is prohibited from negotiating reimbursement rates or fee schedules on behalf of their members due to the Sherman Act (https://bit.ly/43DTUMx). Under this Act, even indirect coordination, such as sharing pricing benchmarks, can be construed as illegal price fixing, a per se violation according to the Department of Justice (DOJ) (https://bit.ly/3X3kPOa).

Similarly, associations must avoid encouraging members to collectively refuse to contract with a payer, which constitutes a group boycott. The DOJ and Federal Trade Commission (FTC) have flagged information sharing among competitors as a potential antitrust issue. To be compliant, associations must ensure that their activities do not facilitate collusion or coordinated behavior among members (https://www.justice.gov/atr/healthycompetition). For the same reasons, it is strongly recommended that providers and associations consult legal counsel when developing coordinated advocacy strategies that involve payer interactions, especially strategies that touch on contracting or reimbursement.

What AOTA Can Do

The good news is that AOTA does have several ways that it can advocate with private insurers on your behalf. These include promoting the inclusion of occupational therapy services in benefit designs, advocating for fair credentialing and recognition of provider qualifications, expanding the list of billable CPT codes, and pushing for transparency in coverage and utilization management policies.

Additionally, to support OTPs in their day-to-day responsibilities, AOTA assists members by offering educational resources, tools for appealing denials, guidance on payer policies and credentialing, and billing and documentation requirements. By providing tools and support, AOTA empowers OTPs to advocate for themselves and their clients within the constraints of payer systems.

AOTA also plays a critical role in the AMA’s Relative Value Scale Update Committee (RUC) process. As a member of the Health Care Professionals Advisory Committee (HCPAC), AOTA represents occupational therapy in the valuation of CPT codes (https://bit.ly/4pnes4p). This involves conducting surveys of OTPs to gather data on service complexity, submitting recommendations for work Relative Value Units (RVUs), and collaborating with other therapy organizations to ensure appropriate valuation. Through this process, AOTA has successfully advocated for new codes—such as caregiver training services without the client present—and defended existing ones against devaluation. These efforts help maintain reimbursement under Medicare and influence commercial payer policies that often mirror Medicare rates.

What OTPs Can Do

There are a couple of avenues that providers can use to facilitate payer-provider communication without violating antitrust laws. The first approach is the messenger model (https://bit.ly/47Q7aQM). One example of a messenger model that many are familiar with is an Independent Practice Association (IPA). In this approach, a neutral party (e.g., an IPA) acts as a middleman, conveying payer offers to individual providers, who then independently decide whether to accept them. This method avoids collective negotiation and maintains compliance.

Another avenue is the formation of clinically integrated networks (CINs), which allow joint contracting if providers are clinically or financially integrated. CINs must share governance, infrastructure, and performance accountability, and implement evidence-based protocols. These networks are increasingly used by independent providers to engage in value-based contracting. CINs also offer a framework for quality improvement and data sharing, which can enhance care coordination and outcomes.

Finally, individual OTPs can try to negotiate directly with insurance companies for better reimbursement. Often, providers start with state or regional payers. Negotiating a contract and/or reimbursement requires OTPs to be very familiar with their market and be able to articulate their unique value. Deliberations about reimbursement and other terms can be bolstered by data, especially outcomes data, so OTPs are strongly encouraged to collect and analyze their data to provide a solid value proposition for the payer. Practitioners should also routinely review and analyze their payer contracts to understand the specific terms that can be discussed and negotiated with the payer. AOTA’s Private Practice Essentials for Reimbursement (https://bit.ly/4phgqmv) resource guide has a section on contracting with commercial insurance companies https://bit.ly/4r4FUFp) that can help guide individuals through contract analysis.

Lessons Learned

AOTA often meets and builds relationships with commercial insurer organizations to improve occupational therapy coverage. These meetings focus on clarifying the definition of occupational therapy services, advocating for fairer reimbursement structures (not pricing), sharing evidence about current occupational therapy practice, and reducing administrative complexity. By maintaining open lines of communication and presenting evidence-based recommendations, AOTA helps shape payer policies that better reflect the value of occupational therapy.

Real-world advocacy efforts by AOTA and its partnership with state associations illustrate how strategic engagement can lead to meaningful policy change. In Connecticut, OTPs faced a significant challenge when Anthem Blue Cross Blue Shield implemented a reimbursement cap that threatened access to care. AOTA collaborated closely with the Connecticut Occupational Therapy Association (ConnOTA) to coordinate a response. Through joint advocacy, including direct communication with the insurer and mobilization of affected providers, the policy was ultimately reversed, restoring fair reimbursement and preserving patient access. It is important to note a critical difference between this type of advocacy and antitrust activities. In this case, AOTA and ConnOTA were not colluding with individual providers to set prices. The advocacy efforts were against a capitated fee, a type of reimbursement structure. Anthem was still able to negotiate individual provider payment rates without undue influence from the associations.

Likewise, member engagement often leads to positive policy changes for occupational therapy. For example, AOTA received feedback from members experiencing administrative burdens when billing CPT codes 97530 and 97533 together. Although a modifier could be used to indicate that the services were separate and distinct from each other, Medicaid payers were increasingly requesting medical records before processing claims to confirm there was no service duplication. AOTA leveraged this member input to address the issue nationally (https://bit.ly/44eVvbG), successfully advocating for removal of the modifier requirement to allow claims processing without medical review delays.

Some examples of AOTA’s current advocacy efforts within the commercial insurance landscape include ongoing advocacy for coverage of sensory integration, limiting the burden of prior authorization, and promoting value-based reimbursement models for therapy services that reflect the value of occupational therapy.

Outside of payment and reimbursement, AOTA focuses on advocacy, collaboration with other associations to amplify our message, and education for members on payer policies and best practices. Many of AOTA’s educational offerings emphasize the importance of understanding payer policies, documenting medical necessity, and using appropriate coding. Member engagement is also critical—OTP participation in surveys, grassroots campaigns (https://www.votervoice.net/AOTA/home), and feedback mechanisms (regulatory@aota.org) strengthens AOTA’s advocacy efforts.

Advocacy with commercial insurers is essential to ensuring access to occupational therapy services. Although antitrust laws impose clear boundaries, AOTA, state associations, and OTPs can still play a powerful role in shaping payer policies. By focusing on coverage, education, and strategic collaboration, AOTA can continue to advance the interests of OTPs and the occupational therapy profession.

What the 2026 MPFS Means for Occupational Therapy Providers

January 1 marked the start of new Medicare Part B policies that impact the delivery of skilled occupational therapy services. You can read more about these changes in AOTA's Medicare Physician Fee Schedule final rule summary (https://bit.ly/47T26JS).

Julie Lenhardt is AOTA’s Manager of Reimbursement and Regulatory Policy.