Reimbursement Tips & Other Stuff

This news release from the AMA reports the dirty little secret of our current medical reimbursements system, namely it doesn’t work. Read on.

New AMA Health Insurer Report Card Finds Need for More Accuracy
Eliminating health insurer errors could amount to $15.5 billion in savings

The American Medical Association (AMA) today announced that one in five
medical claims are processed inaccurately by health insurers, according
to the AMA’s third annual check-up of the nation’s commercial health
insurers and the systems they use to manage and pay claims.

This was the key finding of the AMA’s 2010 National Health Insurer
Report Card, which for the first time, benchmarked the overall claims
processing accuracy of the nation’s largest health insurers.

“The finding that one in five medical claims are processed by insurers
with errors emphasizes the huge potential for reducing administrative
costs for physicians and insurers,” said AMA Immediate Past President
Nancy H. Nielsen, M.D.

“Creating a single transparent set of processing and payment rules for
the health insurance industry would create system wide savings and allow
physicians to direct time and resources to patient care and away from
excessive paperwork.”

According to the AMA’s findings, the health insurance industry as a
whole has about an 80 percent accuracy rate for processing and paying claims.

Coventry Health Care Inc. came out on top of the seven commercial health
insurers measured by the AMA with a national accuracy rating of 88.41
percent.

Anthem Blue Cross Blue Shield rounded out the list with a national
accuracy rating of 73.98 percent.

The AMA estimates that $777.6 million in unnecessary administrative
costs could be saved if the health insurance industry improves claims
processing accuracy by one percent. Increasing the health insurance
industry’s accuracy rating to 100 percent would save up to $15.5 billion
annually that could be better used to enhance patient care and help
reduce overall health care costs.

“Each insurer uses different rules for processing and paying medical
claims, which cause complexity, confusion and waste,” said Dr. Nielsen.

“Simplifying the administrative process with standardized requirements
will reduce unnecessary costs in the health system and eliminate the
variability that makes it necessary for physicians to maintain costly
claims management systems for each health insurer.”

Currently, the health care system spends as much as $210 billion
annually on claims processing.

One recent study estimated physicians spend the equivalent of five weeks
annually on health insurer red tape.

To keep up with the administrative tasks required by health plans,
physicians divert as much as 14 percent of their revenue to ensure
accurate payments from insurers.

This piece originally appeared in the Psychiatric Times

With billions of dollars for electronic health record (EHR) technology purchases hanging in the balance, psychiatrists need to be paying attention to the Department of Health and Human Services (HHS) deliberations on the definition of “meaningful use.” HHS Secretary Kathleen Sebelius is supposed to set an interim definition in a few months. This is important to all office-based physicians because it will set the requirements they will have to meet for proving they are making meaningful use of EHR software and hardware they previously purchased. If they can make the case, starting in 2011, they would qualify for federal grants to partially compensate them for those previous software and hardware purchases.

Those grants are available for 5 years, and if obtained starting in 2011, they could amount to as much as $64,000 per practice for psychiatrists whose patient mix is at least 30% Medicaid recipients. That figure falls to $44,000 for physicians who cannot meet the Medicaid percentage and who see Medicare patients, with no specific percentage of the latter being designated.

There is also a penalty for physicians who do not meet the meaningful use definition. It comes into play after 2016; the Medicare fee schedule for professional services is reduced by 1% in 2015, by 2% in 2016, by 3% for 2017, and by between 3% to 5% in subsequent years.

The grants were authorized by the American Recovery and Reinvestment Act (ARRA)—which is the stimulus bill Congress passed last winter. Sebelius will set interim requirements based on recommendations from 2 new advisory committees that were established by the ARRA: a health information technology policy and a standards committee. The meaningful use requirements will be different, in part, for office-based physicians and hospitals, but they will have escalating requirements in 2011, 2013, and 2015.

The ARRA gave HHS some guidelines as to what the meaningful use definition should include. The overriding requirement is that a physician be able to exchange certain categories of patient data electronically with other providers and to report quality measures to the HHS and Centers for Medicare and Medicaid Services (CMS).

Complying with a meaningful use definition may have some general and specific challenges for psychiatrists. To begin with, it looks likely that all physicians would have to use computer physician order entry (CPOE) for all patients. In 2011, CPOE would have to perform certain basic tasks. For example, it would need to be able to implement drug-drug, drug-allergy, drug-formulary checks; maintain an up-to-date problem list of current and active diagnoses; and generate and transmit permissible prescriptions electronically. In addition, certain quality measures would have to be reported to the CMS. Those would include, on the basis of the policy committee’s final recommendations, percentages of:

* Diabetic patients whose glycosylated hemoglobin levels are under control

* Hypertensive patients whose blood pressure is under control

* Patients with dyslipidemia whose LDL levels are under control

* Smokers to whom smoking cessation counseling and other measures are offered

At meetings with HHS officials this summer, and in comments, the American Psychiatric Association (APA) pointed out that the elements of the meaningful use definition were shaped for generalists—not specialists such as psychiatrists, for whom some of the requirements might pose serious adherence problems. For example, about the reporting of quality measures, none of those endorsed by the policy committee included mental illnesses. “Additionally, there are some quality measures which could be incorporated into primary care and some specialty settings which were not included on the committee’s proposal, such as those pertaining to major depressive disorder,” said James Scully Jr, MD, medical director and chief executive officer of the APA in a letter to HHS this summer.

It is not that quality measures for psychiatrists do not exist. They do. The New York State Office of Mental Health has developed a decision support and quality improvement system for what in that state are called “Article 31” hospitals, which are for psychiatric patients. The Psychiatric Services and Clinical Knowledge Enhancement System affects only psychiatrists at those hospitals.

According to Hao Wang, PhD, deputy commissioner, chief information officer, office of mental health, state of New York, the state weeds through Medicaid data for indications that psychiatrists at Article 31 hospitals may be outside the boundaries of good practice in 2 areas in which the state has developed quality indicators: polypharmacy and cardiometabolic syndrome indicators. Psychiatrists who appear to need some help in those 2 areas are required to report to the state office of mental health to ensure they are improving their stats. Wang suggests that those 2 quality indicators have utility beyond psychiatrists and could be used by HHS if it wanted to make its quality measures reporting definition more relevant to psychiatric practice.

Wang stated what everyone already knows: that psychiatrists—and physicians more broadly—have not exactly flocked to EHRs. But psychiatrists may have a particular disincentive, Wang explained, “because they can’t find a good behavioral health care product.” He added that hospitals are more concerned about patients with physical conditions, because they generate more revenue. And EHR vendors have responded to that by producing systems that have little utility for physicians who see high percentages of patients with mental health conditions.

17 states now require health plans to cover autism treatment. They are: Arizona, Colorado, Connecticut, Florida, Illinois, Indiana, Kentucky, Louisiana, Maine, Montana, Nevada, New Jersey, New Mexico, Pennsylvania, South Carolina, Texas, and Wisconsin.

N.B. Services covered and the dollar value of the coverage varies by state, however, the extension of coverage will open up the market for autism services.

Technology:

Keeping Electronic Records with Carepaths

Colleen Byrne, Ph.D.

Since early 2005, the Psychology Clinic at the University of Maryland in College Park has been using the Carepaths for electronic record-keeping. In hopes of both simplifying our record-keeping and also cutting paper costs, we switched to electronic record-keeping with Carepaths. I originally learned about Carepaths from Eric Sauer. Although I had intended to use it only for the OQ45, I gave the electronic record-keeping function a trial run and ended up liking it a lot. CarePaths offers the eRecord, “a multi-modal, web-based Behavioral Health Electronic Medical Record (EMR) and Practice Management system.” It is a “secure, web-based and HIPPA-compliant record-keeping system”. It is also highly customizable. Our Clinic uses only 30-40% of Carepaths’s available services.

For our Clinic, the main benefits of using Carepaths are 1) low cost as compared to products like Titanium, 2) the convenience of access from any secure, internet-connected computer, and 3) the security provided by customizable access levels for supervisors, practicum students, and support staff. Additionally, electronic record-keeping has increased efficiency and accountability for practicum students and supervisors alike. The web-access is a good fit for students with hectic schedules; I find that students have been more likely to write progress notes on time now that the time and date are electronically stamped. This has been true for supervisors as well. Electronic record-keeping has made it easier for supervisors to monitor the progress of a multiple students’ work. Also, students in need of assistance are more easily identified and can be provided with feedback before the end of the semester.

At the UMD Psychology Clinic, we primarily use the following the Carepaths modules: Progress Notes, Clinical Screenings; Assessment Center, Intake Assessments, Treatment Planning, Discharge Planning, Patient Management, and System Administration:

* In the Progress Notes module we use the Individual Progress Note, Miscellaneous Contact Note, and Miscellaneous Service Note;
* In the Clinical Screenings module we use the Clinical Screen template to record basic information about a client’s presenting problem and treatment history;
* In the Assessment Center module we use the OQ45.2, YOQ30, YOQ30-SR, and WAI;
* In the Patient Management module we enter demographic and contact information for waitlisted clients. (With a quick change of the medical record number, this becomes their electronic chart when they are assigned to a therapist); and
* In the System Administration module, which has restricted access, we use the Groups feature (to specify user levels) and Security Keys.

Practically, it works like this. After logging on, a user can enter text for a progress note directly into the template or they can cut and paste from a MS Word document. The practicum students “sign” their work (by entering their password next to their name) as “pending”, which allows supervisors to review and/or make corrections before signing a document as “completed”. If a student wishes to have time to self-edit, they can sign their work as a “draft” so that only they have access until they are ready to submit the document as “pending.”

Carepaths has many features such as scheduling, internal email, accounting, and billing that we have chosen not to use. (Since collected funds are processed through our Psychology Department’s business office, we keep billing and scheduling on separate programs to maximize client confidentiality.) One drawback with Carepaths is that I still need to rely on the practicum students and supervisors to let me know when a case is closed. Further, unlike Titanium and some other products, Carepaths does not offer query-type searches of clients based on demographic or diagnostic variables. (So, if I wanted to know how many depressed males came to our Clinic in the last year, there is no quick way to find out). I can’t say that Carepaths will work for every Clinic, but it has been wonderful for us.

To contact Carepaths: Go to http://carepaths.com call 800.357.1200. Ask for Geoff Gray and identify yourself as a Clinic Director and member of ADPTC.

CarePaths is currently working to meet the anticipated standards for EMR certification. The standards will address interoperability of EMRs so that information can be passed back and forth between different systems. In behavioral health it is anticipated that a Continuity of Care document will be used. This document will pull essential information from the behavioral health chart (e.g. medications, diagnosis, etc) and allow for uploads and downloads to EMRs of other providers. Currently, CarePaths is working on the technical infrastructure for EMR interoperability.

What follows is a recap of the HITECH act. This act states that “eligible professionals” who demonstrate “meaningful use” of a “certified EHR” will qualify for stimulus funding and incentives.

Definitions:

Eligible professional are office-based physician.

Meaningful use includes use of ePrescribing and quality measures reporting as designated by the Health and Human Services Secretary.

Certified EHR HIT Standards have yet to be finalized nor have the organizations been selected who will conduct the certification.

Providers may receive reimbursement incentives from either Medicare or Medicaid but not both.

MEDICARE INCENTIVE

Providers may receive up to $44,000 over five years for proving meaningful use of a certified EHR.

First payment year: $18,000 if first payment year is 2011 or 2012
$15,000 if first payment year is 2013
$12,000 if first payment year is 2014

Second payment year: $12,000
Third payment year: $8,000
Fourth payment year: $4,000
Fifth payment year: $2,000

Eligible professionals working in health professional shortage areas (HPSAs) will receive a 10% increase in incentive payment amounts.

MEDICARE PENALTY

Providers who have not begun to demonstrate meaningful use of an EHR by 2015 will experience a reduction in Medicare fee schedules as follows:

2015: 99%
2016: 98%
2017 and on: 97%

MEDICAID INCENTIVE

In order to qualify for the Medicaid incentive, providers must rely on Medicaid assistance for at least 30% of their patient volume. For eligible Medicaid providers, the State is authorized to provide reimbursement for 85% of net average allowable costs of EHR adoption and startup – up to $63,750 over 6 years. Medicaid incentives for EHR adoption will begin in 2011. There are no set Medicaid penalties for lack of EHR adoption.

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.