Premera Is Reducing Therapy Payments Starting 4 December 2026
Sometime in December, a therapy office in Washington or Alaska is going to open a remittance, see less money than expected, and start hunting for what they did wrong.
Nothing. They will have billed it exactly the way they billed it in November.
Premera approved version 4.0 of its Physical Medicine and Rehabilitation Services payment policy on 18 August 2026. Buried in it is a new payment rule that takes effect for dates of service on or after 4 December 2026. That is about eleven weeks from now, and almost nobody is talking about it.
The short answer
Starting 4 December 2026, when you perform two or more therapy procedures for the same patient on the same date of service, Premera will no longer pay all of them at full allowance.
The highest procedure is allowed at 100 percent of the fee schedule allowance, or your billed charge, whichever is less. Every other therapy procedure on that claim is allowed with a 50 percent reduction of the practice expense component.
Read that last part carefully, because this is where most offices will estimate the damage wrong in both directions.
It is not half your money
The reduction applies to the practice expense component, not to the whole allowed amount.
Every fee schedule allowance is built from three pieces. Work, practice expense, and malpractice. Premera is cutting one of those three in half on your secondary procedures. It is not cutting the line in half.
That distinction matters because therapy codes are practice expense heavy. The equipment, the table, the space, the staff time, those all live in the practice expense component, and it is usually the largest of the three for these codes. So the hit is real and it is meaningful. It is simply not the fifty percent of everything that the phrase multiple procedure reduction makes people picture.
If you want the actual number for your own practice, you will have to run it code by code against your own contracted rates. Nobody can hand you a percentage that is true for every office.
Which codes this touches
Premera is not publishing its own list. The policy points to the multiple procedure indicator on the CMS National Physician Fee Schedule Relative Value file. Any service flagged with a multiple procedure indicator of 5 is in scope. Those are the codes CMS classifies as always therapy.
This is not a new concept. Medicare has run this same reduction on therapy services since 2011. What is new is a commercial plan in this region adopting it. If your office has been quietly absorbing the Medicare version for years without noticing, you are about to notice, because it is arriving on a much larger share of your book.
Who should care
Any practice that routinely bills more than one timed therapy code per visit. Physical therapy, occupational therapy, speech therapy, and chiropractic offices that add therapeutic procedures to a manipulation.
The typical visit that triggers this is the ordinary one. A manual therapy unit, a therapeutic exercise unit, and a modality. That visit has been paying one way for years. In December it pays another way.
The policy covers Premera Blue Cross, Premera Blue Cross Blue Shield of Alaska, LifeWise Health Plan of Washington, LifeWise Assurance Company, and Premera Blue Cross HMO.
While you are in the policy anyway
The unit limits in this same document have been in force for years, and I still find offices billing over them and writing off the difference without ever asking why. Per date of service, per provider:
Supervised modalities, 97012 through 97028. One unit.
Constant attendance modalities, 97032 through 97039. Two units.
Therapeutic procedures, 97110 through 97124, 97139, 97140, 97530, 97760 through 97763, and 97129 through 97130. Four units.
Evaluation or reevaluation, 97161 through 97168. One unit.
Speech therapy, 92507 and 92508. One submission per individual. Speech evaluations 92521 through 92524, one submission.
If your remittances show consistent denials right at these thresholds, that is not a glitch to appeal. That is the policy working as written, and the fix is upstream in how the visit is scheduled and documented, not downstream in the appeal.
The time rules that create phantom units
For codes billed in 15 minute increments, the halfway point is 8 minutes. Anything delivered for 0 to 7 minutes is not billable at all.
For codes billed in 30 minute increments, the halfway point is 16 minutes. Anything from 0 to 15 minutes is not billable.
Modifier 52 for reduced services is not recognized on timed modality or therapeutic services. You cannot use it to bill a short session at a reduced rate. Either the time threshold was met or the unit does not exist.
The modifiers that have to be there
Always therapy codes require a plan of care modifier. GP for physical therapy, GO for occupational therapy, GN for speech language pathology. This has been required since August 2022 and it is still one of the more common reasons a clean looking claim comes back.
Assistant services carry their own modifiers. CQ when the service was furnished in whole or in part by a physical therapy assistant, CO for an occupational therapy assistant. Those services are billed only by the supervising therapist, on separate lines.
What to do in the next eleven weeks
Pull a month of your Premera therapy claims and count how many dates of service carry two or more always therapy procedures. That percentage is your exposure. For most therapy offices it will be most of them.
Model it against your own contracted rates for your five most billed code combinations. Not an estimate, the actual arithmetic, using the practice expense portion rather than the full allowance.
Decide now what you are doing about it, while you still have time to choose. That might be a scheduling change, a conversation about your contracted rates, a look at your payer mix, or simply knowing the number so December is not a surprise.
Tell your front desk and your biller before it happens. A biller who knows a reduction is coming posts a remittance correctly. A biller who does not know spends December chasing a problem that does not exist and possibly refiling claims that were paid correctly the first time.
Verify it yourself
The policy is public. Read it rather than taking my summary for it, and check whether Premera has revised it again since this was written, because they revise these regularly.
Premera Physical Medicine and Rehabilitation Services payment policy, CP.PP.099: https://www.premera.com/paymentpolicies/cmi_051744.pdf
Premera payment policy recent updates: https://www.premera.com/wa/provider/reference/payment-policies/recent-updates/
Premera payment policies index: https://www.premera.com/wa/provider/reference/payment-policies/
CMS Physician Fee Schedule lookup, for the multiple procedure indicator on any code: https://www.cms.gov/medicare/physician-fee-schedule/search
One more thing worth saying plainly. This one was findable. It was posted publicly in August for a December start, which is more warning than payers usually give. The practices that get hit hardest in December will not be the ones who were treated unfairly. They will be the ones who were not reading.
Most billing problems leave clues. This one left a dated PDF.
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About the author
Marie Matteson, MS, is a healthcare consultant, educator, and Office Ally specialist with more than 30 years in healthcare, emergency medicine, and practice management. Helping you understand what's really going on.
Website: https://mariematteson.com/welcome
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This article is general billing education and is not legal, compliance, or coding advice for any specific claim. Payment policies are revised frequently and the terms summarized here may have changed after publication. Verify current policy language directly with Premera and against your own provider contract before making any billing or scheduling decision. Marie Matteson is not affiliated with, endorsed by, or sponsored by Premera Blue Cross or Office Ally. CPT is a registered trademark of the American Medical Association.
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