Reimbursement Tips

The new issue of the American Medical Association’s *American Medical
News* includes an article: “How to get paid for care delivered over the
phone” by Victoria Stagg Elliott.

It is possible to get paid for your work on the phone.

It takes the right coding for the right situations, the right
documentation and persistence.

Some research has indicated that 20% or more of the clinical services
provided in some specialties are done over the phone.

But most of the time spent on the phone with patients cannot be
reimbursed, because it is considered part of a face-to-face visit, the
call is short, or the insurer doesn’t cover it.

“These services have very specific guidelines in order to bill for
them,” said Betsy Nicoletti, author of The Field Guide to Physician Coding.

Insurers increasingly are willing to pay for e-mail consultations, but
physicians who deliver care by telephone say voice communication offers
better patient care.

For instance, a billable call can be initiated only by an established
patient or the patient’s guardian.

In addition, the conversation cannot be related to a face-to-face
appointment that occurred within the past week or will happen within the
next 24 hours or the next earliest available appointment.

In other words, the call has to substitute for in-office care.

The relevant codes are:

* 99441: Five to ten minutes of medical discussion.
* 99442: 11 to 20 minutes of medical discussion.
* 99443: 21 to 30 minutes of medical discussion.

* 98966, 98967 and 98968: The comparable codes for care provided by
other health professionals.

To increase the likelihood of payment, the call must be documented like
an in-person visit, with particular notation of the time spent.

In addition, experts advocate spelling out in contracts with insurers
that such services will be covered.

If an insurer does not cover phone calls, it may be possible to bill
patients separately.

Most insurers allow patients to be billed for medically necessary
noncovered services.

Most medical societies, including the American Medical Association,
support payment for medically necessary care provided by telephone.

The mental health parity will take effect January 1, 2010. The new legislation requires employer-sponsored health insurance with behavioral health benefits to ensure equality between physical and mental health treatment in copayment, coinsurance, deductible, out-of-pocket expense, and days of coverage, frequency of visits, and frequency of treatment. However, the legislation does not apply to health insurance plans offered by employers with 50 or fewer employees or to health insurance plans that provide no behavioral health benefits. Plans that experience a cost increase attributable to parity of more than two percent in the first year or one percent in subsequent years can obtain a short-term exemption that must be re-established regularly and supported by actuarial data.

The legislation affects health insurance plans provided by employers with 51 or more employees and self-funded plans regulated under the Employee Retirement Income Security Act. The plans must ensure equality of out-of-network benefits for mental health and addiction treatment services and equality in treatment limitations and financial requirements. The parity provisions only apply to insurance plans that provide mental health coverage. Plans that experience a cost increase of more than 2% in the first year, or 1% in subsequent years, will be able to apply for an exemption.

What will the parity legislation mean for the field? It will be immense. Consider:

* Limited benefits for mental health and addiction treatment cause this niche of the health care field to be unattractive to health care provider organizations.
* People with addictions and mental illnesses leave their places of employment in order to become eligible for Medicaid and eligible for treatment benefits because they either do not have employer-sponsored health insurance or their insurance coverage for their behavioral disorders is inadequate.
* Health insurers create benefit plan designs with very limited mental health and addiction treatment benefits, which result in cost shifting to the consumer or state or county governments.
* Lack of availability of mental health and addiction treatment causes “miscoded” service delivery in many other systems — primary care, child welfare, juvenile corrections, and more.
* Inadequate addiction treatment and mental health benefits create overutilization of emergency rooms. (More clinical crises result from lack of timely, appropriate treatment — and emergency rooms are the only treatment site for most of those folks.)
* Our prisons are populated with untreated, undertreated, and ineffectively treated people with behavioral disorders.
* Limited benefits for mental health and addiction treatment make this niche of health care unattractive to investments dollars — in software and systems, in clinical technologies, and in facilities.

Overall, the major industry effect of the parity legislation is that mental health and addiction treatment spending in the health and human services system — currently distributed in miscoded general health care spending in primary care and emergency rooms and pushed to the social service system — will be correctly classified as spending on treatment for behavioral disorders. This will have a number of key market effects. First, the parity legislation will change how we account for health care spending resulting from behavioral disorders. A number of actuaries predict that the health insurance premiums will rise 1% to 2% in total as a result of the parity legislation. This translates into a 30% increase in mental health and addiction treatment spending within health plans affected by the legislation (assuming a national average premium for treatment of behavioral disorders of 6.2% of total health plan spending).

The increase in funding for treatment of mental illnesses and addictions brought about by parity will make the treatment of these disorders attractive to a wide range of provider organizations and health care systems. For consumers, this will be a boon — more choices from a wider range of treatment providers. Look for a reversal in the current trends for community hospitals to abandon psychiatric programs. However, for current specialty provider organizations, this change will mean more competition for consumers.

More people with mental illnesses and addictive disorders will stay in the workplace and employed — though these market effects will be limited by the bill’s provision exempting self-funded health plans (which includes most large employer plans). The combination of the newly-expanded Americans with Disabilities Act, better treatment tools, and equity in treatment benefits mean that more treatment will occur in the employer-sponsored health plans than ever before. This will take some of the pressure off of state and county mental health and substance abuse budgets, which have been the recipients of planned cost shifting from health insurance plans.

All of these changes to the delivery system resulting from the market effects of parity will likely increase the integration of the treatment of mental illnesses and addictions into the primary care system. As primary care provider organizations see the ability to provide treatment services that are reimbursed by insurers, their interest in integrating these services into their practices will increase.

The parity legislation should have positive effects–lower spending– on budgets for hospital emergency rooms, child welfare agencies, and the juvenile and adult corrections systems. It will take at least five years to see these shifts in service utilization due to lack of access to treatment — but they are likely to happen over time.

With these changes in the field, we should see an increase in investment dollars in areas focused on treatment of mental illness and addiction treatment. This area of health and human services has been capital deprived due to the very correct perception that the field had lots of demand but limited payment for treatment services. There should be increasing capital available for biotechnology, software, and facilities focused on behavioral health disorders.

For provider organizations with large portions of their budget dependent on “safety net” types of funding (state block grants, federal program grants, etc.), look for a reduction in “safety net” funding specific to mental health and addictions — with an increase in safety net funding for the uninsured in general.

The Medicare Improvements for Patients and Providers Act (MIPPA) becomes effective January 1, 2010. It is expected that parity will mean a 30% increase in behavioral health spending over the next five years.

As the parity provisions are phased into Medicare, there is a formula for calculating the decreased amount for patient copayments using a series of phase-in multipliers. The phase-in process will not apply to two outpatient mental health services which will both be covered at 2014 rates immediately. They are brief office visits for monitoring or changing drug prescriptions used to treat a mental health disorder (cpt codes 90862 and 90805) and partial hospitalization services billed by hospital outpatient departments and community mental health centers. However, since the professional services of providers to partial hospitalization are billed separately from the partial hospitalization program of services and their services are subject to the MIPPA changes in the limitation.

Diagnostic evaluations (cpt codes 90801 and 90802) and tests to establish or confirm a patient’s diagnosis are also not subject to the MIPPA. CMS instructed Medicare contractors to deem initial visits as diagnostic. In cases where a diagnosis takes more than one visit, the Medicare contractor may request documentation to justify the additional visit.

On November 13, 2009, the Centers for Medicare and Medicaid Services (CMS) released Medicare claims processing information on how mental health parity for outpatient mental health services will be phased-in. Before the Medicare Improvements for Patients and Providers Act (MIPPA) was signed into law on July 15, 2008, patients paid half the cost of Medicare-covered outpatient mental health services, but only 20% of the cost of Medicare-covered outpatient medical services. MIPPA equalized the coverage rates, so that as of January 1, 2014, Medicare Part B will pay outpatient mental health services at the same level as other Part B services. Outpatient mental health services are available for psychiatric diagnoses described in the International Classification of Diseases, 9th Revision (ICD-9), under the code range 290 to 319.

According to an October 30, 2009 CMS manual update to Medicare contractors, “Medicare Claims Processing Transmittal 1843: Outpatient Mental Health Treatment Limitation,” for outpatient mental health services provided before January 1, 2010, the pre-parity coverage rate will still be in effect. After meeting their deductibles, patients will pay 50% of the covered charges and Medicare will pay the other 50%. The phase-in process and percentages apply to claims for professional services provided by physicians, clinical psychologists, clinical social workers, nurse practitioners, clinical nurse specialists, and physician assistants. The phase-in process also applies to diagnostic psychological and neuropsychological testing to evaluate a patient’s progress during treatment.

To determine how much patients pay and how much Medicare pays, of the actual charges, the Medicare-approved amount will be multiplied by a limitation percentage to find the Medicare incurred expenses. The patient’s unmet deductible is subtracted, and the remainder multiplied by 80% to find the amount Medicare pays. The rest of the Medicare-approved amount is the patient’s responsibility. For the pre-parity coverage, the multiplier was 62.5%. The phase-in multipliers will be as follows:

* 68.75% as of January 1 (with an implementation date of January 4, 2010), through 2011; patients will pay 45% of covered charges; Medicare will pay 55% of the covered charges.
* 75% as of January 1, 2012; patients will pay 40% of covered charges; Medicare will pay 60%.
* 81.25% as of January 1, 2013; patients will pay 35% of covered charges; Medicare will pay 65%.
* 100% as of January 1, 2014; patients will pay 20% of covered charges; Medicare will pay 80%.

Two outpatient mental health services will be covered at the 2014 rate immediately. The phase-in process will not apply to brief office visits for monitoring or changing drug prescriptions used to treat a mental health disorder. These visits are reported using HCPCS code M0064. CMS instructed Medicare contractors that procedures identified as HCPCS code M0064 or any successor code will not be subject to the phase-in process. Diagnostic evaluations and tests to establish or confirm a patient’s diagnosis will also not be subject to the phase-in process. CMS instructed Medicare contractors to deem initial visits as diagnostic. In cases where a diagnosis takes more than one visit, the Medicare contractor may request documentation to justify the additional visit.

The new issue of the *Psychiatric News* (vol. 44, #22) Includes a Q & A
from the American Psychiatric Association’s HelpLine Database on how to
bill for phone therapy.

Key points are:

1) There is no CPT code for conducting psychotherapy over the telephone.

2) All the psychotherapy codes are described as face to face with the patient.

3) The only appropriate code to use would be 90899, “unlisted psychiatric
service or procedure.”

If you use this code, you should provide documentation describing that
it is for psychotherapy over the telephone. This could could also be used for other unlisted psychiatric services or procedures, e.g. outcomes assessment using a standard instrument.

There are timed codes for E/M services provided on the telephone (99441:5-10 minutes; 99442: 11-20 minutes; 99443: 21-30 minutes). These codes can be used for medical discussion with a patient for whom you have not provided an E/M service within the past seven days and whom you would not be seeing for the reason discussed in the call.

You know it’s the real thing when the insurance companies are backing up the idea with real money. This from the Washington Times, Oct 4,2009:

“United Health Group and Cisco Systems, a technology firm, recently announced a partnership operation of what they call “the first national telehealth network,” expected eventually to connect 600,000 physicians and 5,000 hospitals nationwide. As part of the effort, an 18-wheel mobile van equipped with the latest in videoconferencing equipment and suitable clinical tools is scheduled to undertake several pilot projects.

First up is a visit to rural New Mexico this summer, in conjunction with Project HOPE, to tackle diabetes and other chronic diseases. The van also helped with back-to-school immunizations in Baltimore in early September.”

“It’s the first time a private payer has really come out in a big way and endorsed telemedicine. … The insurers are starting to say yes,” notes Jonathan Linkhouse, CEO of the American Telemedicine Association. “Telemedicine doesn’t have to be high tech. There is a huge benefit in terms of keeping people out of hospitals.”

TRICARE Offering Telehealth Program – ATTN: Behavioral Health Prescribing Providers

Effective August 1, 2009, TriWest Healthcare Alliance will be implementing the new TriWest Online Care program, a program to increase behavioral health service for TRICARE active duty service members (ADSMs) and active duty family members (ADFMs) via telehealth services.

Providers can participate in this exciting opportunity as an Originating Site Facility or a Distant Site Facility. An Originating Site is the site where an eligible TRICARE beneficiary is located when the service is being furnished via a videoconferencing system. A Distant Site is the location where a TRICARE provider will render services being furnished via a videoconferencing system. TRICARE will reimburse for both types of services.

One of the areas in which we need to augment existing access to providers is in the area of behavioral health prescribers. Our TRICARE beneficiaries, particularly those located in rural areas, would benefit from additional access to those distant providers who can prescribe medications to behavioral health patients. Only network providers located in the West Region are currently eligible to participate in the demonstration project with TriWest.

TriWest sent an e-mail survey on June 10 to providers with information in order to gauge interest in participating in the program. If you are interested in providing additional care options for your TRICARE beneficiaries by offering space in your office for beneficiaries to access these services or by becoming a TRICARE Distant Site Behavioral Health Care provider, please click this link and complete the short questionnaire identifying your potential interest. The local network representative will follow-up with those providers indicating an interest. If you already have responded to the survey and have been contacted by your local network representative, there is no need to take the survey again. If you are interested in participating, please respond to the survey by Friday, June 26.

Here are the links to information regarding distant sites and originating sites. For more information regarding TRICARE Telemedicine policies, please refer to the TRICARE Policy Manual, Chapter 7, Section 22.1, at www.tricare.mil.

The excerpts below provides guidance to psychiatrists on contracting with private insurers. Most of the suggestions apply to other mental health professionals as well. However, psychiatrists are in a unique situation–the majority of psychiatrists do not contract with MCOs (psychiatrists are more apt to be fee for service than any other medical specialty) and there is an undersupply of psychiatrists on many private insurers panels. This gives psychiatrists significant leverage in negotiating with MCOs.

Here is the excerpt:
(MCOs) can affect many aspects of your practice, including how much you are paid, which services you are permitted to provide, and how you are expected to provide them. So before you sign any contract, it’s vital that you take the time to read it thoroughly.

Each contract is different, even from the same company.

Also, don’t assume that a renewal contract is the same as the one received “last year.” Often it is not.

Companies may include important contract features in appendixes, addendums, or “attachments” such as provider manuals, which, if you’re not careful, you may be unaware of until it’s too late.

You must be certain to obtain all documents referenced in a contract and to review them all before entering into a contract.

While some contracts may apply to only specific settings, others stipulate that an in-network psychiatrist is in-network at every place he or she provides services.

This requirement has been problematic for some psychiatrists who practice in clinics that accept many forms of insurance but who have private practices where no insurance is accepted.

If the clinic’s contract with an insurer says it covers all its psychiatrists in all practice settings, then psychiatrists who see a
patient in that plan in their private practice are considered in-network providers there as well and will be paid only the in-network fees negotiated under the clinic contract.

Even if the clinic’s contract with the insurer does not stipulate that all places of service are covered, psychiatrists who want to be
considered out of network in other settings must notify the insurer of this fact.

Because many insurance companies are having trouble maintaining an adequate number of psychiatrists in their networks to meet enrollees’ needs, they may make it difficult for psychiatrists to sever their relationship.

APA’s Managed Care Help Line has received calls from members who were unable to get out of their contracts for many months because an insurer maintained it hadn’t received faxes or e-mails that the doctors had sent to convey their change in status.

We recommend that any notifications about a change in status with an insurer be done in writing and be sent by registered mail, return receipt requested.

Other Points to Remember

* Review the contract for any billing and balance-billing provisions
that restrict your ability to bill patients.

* Review credentialing requirements. Personal information, such as
medical history, may be unwarranted if it does not currently affect your
ability to practice….

* Study the confidentiality terms in the contract; federal and state
laws supersede contractual requirements.

* Study utilization-review requirements to learn procedures for prior
authorization, concurrent review, retrospective review, use of formulary
restrictions, access to physician reviewers, and appeal mechanisms.
These topics are frequently covered in the provider manual, which you
should review before the execution of a contract.

* Be aware that contracts give insurers the right to conduct quality-
assurance audits. This is standard and will not create any problems for
you if you do appropriate documentation.

* Pay attention to how the insurer authorizes services in an emergency.
Most companies have a utilization-management process in place that can
authorize emergency services at any time, but the flexibility of the
authorization process varies. Ask detailed questions about the process
before signing a contract.

* Know when each of your current contracts expires and consider
renegotiating if you feel you are not being adequately compensated. You
have nothing to lose.

* Ask questions. Contract negotiation may be possible, especially since
there is such a shortage of psychiatrists on insurance panels. Even if
you cannot negotiate, be sure to ask questions on items about which you
are unclear to ensure you are not entering into a contract that you
can’t live with.

* Make sure that all representations are in writing. You should obtain
any changes or clarifications to the terms of the contract in the body
of the contract itself. Any additional clarifications made by
representatives of the insurance company that do not agree with the
contract should be incorporated in an amendment that conforms to the
contractual requirements.

Summing It Up

We can’t emphasize it too much: Don’t sign any contract until you’re sure you thoroughly understand what you’re agreeing to.

Also, always check with your malpractice carrier to make sure nothing in the contract conflicts with your policy. And always check with your lawyer.

The AMA has created a detailed model managed care contract, with annotations that explain the reasons for including its various components.

In an ideal world, this is the kind of contract you’d be presented with when you join an insurance network.

The model contract is posted at .

A more in-depth discussion of contracting, which includes definitions of the terms you may encounter in a contract, is posted at
.

If you have other questions about contracting, call APA’s Managed Care Help Line at (800) 343-4671.

Clinicians can provide (”remotely telepresent”) telemedicine services to medicare beneficiaries so long as those beneficiaries are at a “qualified originating site.” What is an originating site you ask? An originating site must be one of the following: a physician’s or practitioner’s office; a hospital; a critical access hospital; a rural health clinic; a federally qualified health center; a skilled nursing facility; or a community mental health center. Also, originating sites must be located in either a non-Metropolitan Statistical Area (non-MSA) or a rural Health Professional Shortage Area (HPSA). In case you were wondering there is no map of MSA’s or HPSA’s.

Assuming that you think your prospective patients meet these criteria, here are some tips on getting reimbursed:
1) Arrange to collect co-pays. Originating site fees are currently reimbursed at $23.35, payable at 80%. The beneficiary at an originating site owes the balance due.
2) If the patient has an Medicare Advantage Plan other than straight Medicare, make sure that clinicians are in that Plan’s panel.
3) For billing, use the correct the Q3014-GT code for ‘originating site’ billing.
4) Hope for the best!

Mental health disorders costs increased faster relative to the other five highest cost medical conditions: cancer, trauma-related conditions,  heart conditions, and asthma. Mental health expenditures between 1996 and 2006 increased from 35.2 billion in 96 to 57.5 billion in 06. 

The number of people accounting for expenses for mental disorders almost doubled from 19.3 million to 36.2 million between 1996 and 2006.

Of the five top conditions, out-of-pocket payments were highest for the treatment of mental disorders (23.1% and 25% respectively.)