Reimbursement Tips & Other Stuff

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.

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.

Most health plans showed improvement
For physicians, one of the most vexing parts of the claims process is how well insurance plans and Medicare pay the rates as stated in their negotiated contracts. Five of seven health plans significantly improved on this score over 2008 by between 11 and 17 points.