Thursday, October 30, 2014

Blue Cross Blue Shield NC Purges Their Provider Rosters Without Informing ANYONE

I had not had a BCBSNC client in several years when I picked up one a few months ago.  I have a BCBSNC Provider Number given to me by that insurer after filling out a truckload of paperwork 5+ years ago.  I gave my biller the insured person's information and what got spit back out was that I was an 'out of network provider' (death curse).

So, I called them up.  The  client called them up.  The some employee advised me that I had to fill out the reams of paperwork again.  I started crying.  Did she understand how much paperwork she was talking about? Why didn't the company utilize CAQH....an online data base WHOSE SOLE PURPOSE is to keep tabs on providers so that insurance companies can access information like current malpractice insurance/ current licensing information (DUH: you can go to the NC Psychology Board to see if I am 'active' or not). 

As is usual with United HealthCare/ Humana---both Medicare Advantage companies so unregulated that CMS (Centers for Medicare and Medicaid Services) HUNG UP on me when I asked if I could obtain a copy of the new contract these 2 'Advantage' companies had signed with CMS in July, 2014----BCBSNC----which is the 'State Plan' for NC (teachers; state employees)----is very difficult to interface with. 

So, after the crying episode and a period of recovery I resolved to start at the top end of things...that being the NC State Legislature which oversees BCBSNC in terms of the 'State Plan'----figuring it would lead me to info about the company in general.  It did. 

I called the general number for the NC State Legislature.  That lead me to the 'librarian' for them.  That lead me to a manager of the 'State Plan', Thomas Friedman at 919 420 1355.  He indicated that the 'State Plan' had bee assigned 2-3 years ago the Department of the Treasury for the state of NC as things went amuck (gee: wasn't that when the Republicans took over the State Legislature).  Actually, it seemed like a good idea that the 'State Plan' was not being managed in a partisan fashion and the feeling I have gotten from talking to people is that BCBSNC is so powerful that they sit in committee meetings and give the thumbs up or down to things being discussed by the state legislature. 

In any case, Mr. Friedman gave me the telephone number for the overall liason who is the go-between BCBSNC and the state legislature/ Treasure Department.  She is an employee of BCBSNC.  Her number is: Ms. Evans: 919 608 3148. 

This is what I told her: "Hi Ms. Evans. thanks for yr assistance.  As I mentioned I am Marsha V. Hammond PhD, Licensed Psychologist NC # 2748.  NPI is 1194700591.  I am assigned a BCBSNC provider # which was given to me years ago. I can get that if you need it.  As I stated, in February, 2014 I was apparently purged from the BCBSNC provider panel for no apparent reason.  I have a BCBSNC client who works at the canton NC papermill with depression whom I have seen several times over the past several months.  My biller submitted billing which went nowhere and after several very unhelpful conversations with BCBSNC employees they informed me that 'we thought you were out of practice' for no good reason.  My address has not changed.  My license and its status has always been viewable at the NC Psychology Board site.  My CAQH  credentialing information is current.  CAQH is an online management tool that insurance companies use.  BCBSNC is listed there as having access to all my professional information.  I do not believe it is fair or just to require me to go thru months of waiting and dozens of pages of paperwork when I already did that years ago and I have a BCBSNC client requesting outpatient mental health services.  They did NOT inform me of anything for I have reviewed my e mails back to the beginning of 2014.  Besides this there is NO insurance company with whom I am familiar with that purges providers from its roster FOR ANY REASON unless the provider sends to them in writing a request to do so. Thus BCBSNC has violated an industry wide standard and I can only assume the purpose is to create a barrier to care by a well qualified practitioner.  thanks for your help.  Marsha V. Hammond, PhD"

Yeah: we will see where this goes.  I think it will go like this: when the insured calls her number and states something like "M.......f.......... I need for my mental health services to be paid for"...upon which she will say, "What did you say?" (please see previous post for relevance)....and then she will say, "You understood me right, M.......f.........  I want my outpatient mental health services to be paid for..."

Egads: these people just don't seem to respond to anything but point blank rudeness.  Who has all day to dance around their faux nice statements?

Wednesday, October 29, 2014

This is how you get United HealthCare to pay for outpatient Mental Health Services

Can't get United HealthCare, a Medicare 'Advantage' company----completely unregulated at any level in the US----to pay you for outpatient mental health services?  This is how you settle the matter.

1. You file appeal after appeal indicating that that since they lured clients away from Medicare using some guy at Eblen Charities at the back of Earth Fare Grocery store in Asheville, NC who indicated to your client: "We will pay for all mental health services."  So, go get your picket-gear on and hold up your sign which says: "United HealthCare = No Mental Health Care Services.

2. Your client calls up United HealthCare and has the following conversation after numerous attempts at trying to get his outpatient psychiatric and mental health care paid for: "Listen M.......f........"; "What did you say?"; "You heard me right M.......f.........   I am right now in the process of going back to Medicare.  I expect you to pay for my mental health services." 

You can't believe how fast this provider got a letter in the mail indicating that she would be paid back to the beginning of the year. This being said, I don't got no check in my mail box and so I sent yet another appeal to United HealthCare and Maximus Federal who is supposed to monitor them---indicating I had no check tho I had received a letter indicating I would be paid. 

I'll believe it when the check is in my hand.  I advised the very excellent psychiatrist to re-file his billing with United HealthCare. 

Meantime, the client has returned back to Medicare for what they will do once....they will do again.

Saturday, October 25, 2014

United HealthCare Refuses to Pay for Outpatient Mental Health Services

After numerous appeals to United HealthCare (an oxymoronic company described as a "medicare advantage company' by medicare (CMS: Centers for Medicare and Medicaid Services and supported by American Tax Payers----A PRIVATE COMPANY), I am told that outpatient mental health services will not be paid for associated with a client of mine who was LIED TO by this worthless company when he changed from Medicare to United healthcare....all the while being assured that he would be benefited mental health outpatient mental health services----which he had advised them was a 'deal breaker.' 

They don't care. They simply lie. 

Now the client has a huge bill from his psychiatrist.  And I am told that as associated with a 'Waiver of Liability Statement' which I was demanded to sign in order to submit my appeal, that I may not submit my bill to the client whom I advised prior to signing up for any worthless Medicare Advantage company rather than Medicare. 

Maximus Federal, who CLAIMS to "WE WORK FOR MEDICARE" (their bold on the side bar of a letter to me), indicates that as I was 7 days past the 60 day limit to file an appeal...after billing and billing and appealing----that they side with United healthcare---who is supported by American tax payers.  This private company----just like Humana---another Medicare Advantage plan company---has an administrative oversite fee of 18% of better whileas efficient medicare has an administrative oversite fee of <5 p="">
We are a nation of duped people.  We support private companies who ream us with our own tax dollars---all the time believing what they say---which is that they will pay for outpatient mental health care. 

They DON'T; they WON'T; they are COMPLETELY UNREGULATED ACCORDING TO THE NC INSURANCE COMMISSIONER'S OFFICE E.G.,SHIIP.

So why the hell do we put up with them?  I swear...the next time I see that United healthcare van driving around Asheville, NC, I might be inclined to put on my non-reflective Ninja suit and pull out my black spray paint and make a point.  

Friday, October 03, 2014

Lying Medicare Advantage Plans (and CMS, Center for Medicare & Medicaid Services) Which Covers for Them

Twice yesterday I called CMS (Centers for Medicare & Medicaid Services) to ask about the July 2014 contract signed between Medicare Advantage Plans that my clients have with Humana and UnitedHealth Care. 

                                                    Twice I was hung up on. 

I was simply pressing to speak to someone ANYONE at CMS who could give me details about outpatient mental health care changes that have already gone into effect though they are not supposed to until 1.1.2015.  I was told to do this by the NC Insurance Commissioner's Office, the SHIIP Division which oversees Medicare and has no power in any way over Medicare Advantage Plans. 

Prior to calling CMS I called Palmetto GBA, a company which oversees Medicare in NC.  There was no one to speak to AT ALL regardless of what triage tree I tried e.g., "try 1....press 4.....go back to beginning", etc.

In 2008, the NC State Legislature passed a bill which demanded mental health parity.  That is to say, that mental health services were to be covered in a similar manner to physical health services.

Great! But as NC SHIIP personnel at the NC Insurance Commissioner's Office informed me this week, that did not pertain to policies associated with Medicare-eligible consumers.  That would be: disabled people or anyone 65 or older.  THE MEDICARE ADVANTAGE PLANS WERE EXEMPTED.

In July, 2014, Humana; UnitedHealth Care and assumeably, other Medicare Advantage Plans signed a NEW CONTRACT with CMS. This is not well known, to say the least.  I knew that something was up as my remissions came back (for Humana) with half the reimbursement I had received the first half of the year.  (AND AS PER BELOW, THIS IS NOT SUPPOSED TO START UNTIL 1.1.2015 according to the 2015 Medicare Manual, just released to Medicare insured).

And I knew something was terribly wrong with UnitedHealth Care as I have appealed numerous times (if you go over 60 days to appeal they use this as an excuse to gig you) and had been paid nothing to see a client of mine with SPMI (Severe Persistent Mental Illness) who switched from Medicare to UnitedHealth Care 1.1.2014.

 I learned about this'new contract' in a round-a-bout way as associated with talking with Humana/ UnitedHealth Care/ CMS/ NC Insurance Commissioner's Office (SHIIP, specifically, which 'oversees' these plans; according to head of SHIIP in NC, there is NO over-seeing of these plans at all in NC as they are federally mandated/ created plans; she took 2 days to return my calls and then I had to call her).

SHIIP representative John Ciccone in Waynesville, NC has indicated to me that he advises all who come to him the following re: the Medicare Advantage Plans: 1. they have nothing to do with Medicare 2. they are completely unregulated 3. they write their own rules.

I have always advised my clients to stick to Medicare and avoid the Siren-like lures of the Medicare-Advantage Plans----an oxymoron if there ever was one. They are enticed with the promise of cheaper medications, mostly. And these are impoverished people who cannot afford an additional payment related to an extension of Medicare Part D which administers medications.  Psychotropic meds can be very expensive.

In any case, this is my experience these past two weeks re: CMS/ Humana/ UnitedHealth Care as associated with diminished reimbusement (HALF OF MY PAYMENT PRIOR TO JULY, 2014); non-payment after numerous appeals and complaints----and being hung up on twice today by CMS as I asked to have information re: the new contract signed between CMS and these two companies

I will get to NCBCBS in a subsequent post.  They don't even pay though I am a designated provider on their panel since 2008. They tell their insured all kinds of inane stories about how this entity didn't talk to this one; errors codes on my remittance say I am out of network (when I am assigned a number) and any other bullshit you can think of to cause you to pull your run down the street with your hair on fire....

So, let's take a look at the Medicare & You: Official U.S. government Medicare handbook (2015).

Section 5 (page 75): Learn about medicare Advantage Plans (Part C) & Other Medicare Health Plans: 

"In all types of Medicare Advantage Plans, you're always covered for emergency and urgent care." 

                This is a lie as evidenced by the following recent article in the New York Times

 http://www.nytimes.com/2014/09/29/us/costs-can-go-up-fast-when-er-is-in-network-but-the-doctors-are-not.html?_r=0

Costs Can Go Up Fast When E.R. Is in Network but the Doctors Are Not

"....When legislators in Texas demanded some data from insurers last year, they learned that up to half of the hospitals that participated with UnitedHealthcare, Humana and Blue Cross-Blue Shield — Texas’s three biggest insurers — had no in-network emergency room doctors. Out-of-network payments to emergency room physicians accounted for 40 to 70 percent of the money spent on emergency care at in-network hospitals, researchers with the Center for Public Policy Priorities in Austin found.
“It’s very common and there’s little consumers can do to prevent it and protect themselves — it’s a roll of the dice,” said Stacey Pogue, a senior policy analyst with the nonpartisan center and an author of the study...."
SO, relatedly, I have been a Medicare provider for over 10 years.  This allowed me and my clients seamless delivery of services----for after all----they were Medicare Advantage companies----being supported by American tax payer $$---to the tune of 18% overhead administrative costs versus Medicare's 5% or less overhead administrative costs----RIGHT? And prior to July, 2014, the reimbursement was the same---more or less---for outpatient mental health services.

       Correct: until the new contract was signed in July, 2014 which is not to go into effect until 1.1.2015.  

After July, 2014, my remittances revealed as associated with Humana that they were paying me half of what Medicare would pay me for outpatient mental health services....half of what they had paid me prior to July, 2014.

When I called Humana, the woman on the phone did a very fast verbal tap dance around what I was paid until I basically said she was lying. These calls are recorded "for the purposes of training" and so she couldn't hang up.  This apparently was not so regarding the CMS phone calls outlined above.

When I challenged UnitedHealth Care as to why THEY WERE NOT PAYING ME AT ALL after 1.1.2014 for a previously Medicare insured client, they simply ignored me.  Then, mysteriously, after appeals to Maximus Federal which is sometimes mentioned in the small print on the remittances I receive outlining what I am paid and what the client is responsible for---but which was described by SHIIP personnel as a 'ghost entity' which simply feeds back to the companies themselves but which is supposed to be part of CMS----I started being paid by UnitedHealth Care albeit at a lesser rate with a descriptor associated with the money that it was 'tied' to Medicare.

Both of these companies have their mental health care/ behavioral health care outsourced to other companies.  So, you can call them or their ancillary companies and never get an answer----which assumeably is what they count on...that you give up. I call them while I am driving for otherwise I would not be able to work.

To suit, and as related to BUYER BEWARE, the following is in the 2015 Medicare Manual:

"If you're in a Medicare Advantage Plan, review the "evidence of Coverage (EOC) and "Annual Notice of Change" (ANOC) your plan sends you each year...The ANOC includes any changes in coverage, costs, provider networks, service area, and ore that will be effective in January." (NOT JULY). 

Broadly, as associated with 'changes' in Medicare Advantage Plans in NC for 2015, I found this website:

 https://www.careimprovementplus.com/prospectmember/northcarolina-medicare-health-plan-benefits.aspx

2015 Annual Notice of Changes

The documents below are the Annual Notices of Changes for each plan. The information in these documents tells you about the differences between the 2014 and 2015 plan. Please note this is only a summary of changes. It is important to read the Evidence of Coverage to understand how the plan works. For any questions or concerns, please call Customer Service.


DOCUMENT COMING SOON

                                                          Gee, that's helpful.

So, in googling "Humana 2014 Annual Notice of Change" here is what I found:

Humana website: https://www.mymedicareanswers.com/community/news/blog/2014/08/29/question-and-answer-fall-open-enrollment-and-annual-notices-of-change
- See more at: https://www.mymedicareanswers.com/community/news/blog/2014/08/29/question-and-answer-fall-open-enrollment-and-annual-notices-of-change#sthash.VWhaFslx.dpuf

"...Medicare plans may change their coverage rules and costs each year. Every fall, you should receive information from Medicare or the private insurance company administering your Medicare benefits explaining how your Medicare health and/or drug coverage WILL CHANGE FOR THE UPCOMING YEAR. -

And, in googling "UnitedHealth Care 2014 Annual Notice of Change" here is what I found: quite simply put a  compendium of dog-chasing-his-tail information.

Post Script to this fine woman mentioned in the NYT article: Public Policy Priorities in Austin, Stacey Pogue: SISTER, TAKE A LOOK AT THIS. (pogue@cppp.org)

Saturday, February 15, 2014

The Mystery of Two Dorothy/ Dorothea Dixes, both with Mental Health History Issues

Continuing w/ the matter of the Dorothy Dix, who wrote a column in the New Orleans Times-Picayne at the turn of the last century.  She was NOT the DOROTHEA Dix who earlier worked w/ the mentally ill.  This DOROTHY Dix, a pen name she chose as directed by her editor, 'The Major', had this birth name: Elizabeth Meriweather (descended, as I said previously from Meriwether Lewis of Lewis & Clark fame). 

From page 59-60: (in being directed by the editor of the paper to choose a pen name for her Sunday column, w/ she living in New Orleans, having left her mentally ill unstable husband who could not keep a job and had temper control issues):

"....Dorothy Dix....she liked the sound the sound of the words, and so did the Major (the editor), and that was it. Not until years passed did she hear about Dorothea Dix, the New Englander, who worked so devotedly to obtain fairer treatment for the mentally ill.  The newspaper woman's sly adoption of a similar name was no sly allusion, as some thought, to her husband's illness.

Well, isn't this curious? Its as if the younger Dorothy Dix was being 'directed' by the older Dorothea Dix to move in a certain direction...the claiming of her own life, snatching it away from the untoward influence of her mentally ill husband. 

And so Dorothy Dix writes:

"I stood yesterday.  I can stand today. And I will not permit myself to think about what might happen tomorrow."

And like myself, and this blog, referring to Dickens' character, Madame Defarge, the old crone purling away as the heads rolled off the guillotine of the French Revolution, "Nobody could spend a few hours with her without hearing something about a Dickens character." (p. 28)

"....By the time she was fifteen she was putting out her own private newspaper, making herself 'proprieter, editor, contributor, compositor, and sole subscriber..." (p. 31).

And as this Dorothy Dix recognized that she would never have any domestic stability due to her husband's mental instability, dragging them from city to city whereupon he lost job after job, she resigned herself to having no children---a woman who very much wanted children.  And her father, upon seeing how she was suffering, took her to the Mississippi Gold Coast for a long holiday when she was in her early 30's.  Her neighbor introduced her into the Times-Picayne as she resolved that hard work was the only antidote to her sorrow:

"The only panacea for grief is to keep so busy that you have no time to think of your sorrow, and to work so hard that you sleep at night through sheer exhaustion. I know, for I travelled the dark road for thirty-five years, and I should have gone crazy if I'd had enough time to do it."

"Dear Dorothy Dix" : Muse for the 21st Century

Part I: Its a funny thing: I lost my muse re: this  blog: too much work/ little inspiration. 

Part II: I was at the Grove Park Arcade Wine and Book Bar this evening....Val Day...by myself....red leggings and a short black skirt...looking pretty hot....looking thru the NC books section and whadyaknow: stumbled across a lost muse whose name floats across NC re: tearing down her mental health hospital (her husband of 40 years had a mental health challenge which inspired her column of 'Dear Dorothy Dix' at the New Orleans Times-Picayne---not her real name---she was a descendent of the Merriweathers..ya got that right...Meriwether Lewis of Lewis & Clark fame).  Her friends implored her to leave him time and again but she would not.

The subtitle of the book was laughable once you start to look at what and how she wrote:  "Dear Dorothy Dix: The Story of a Compassionate Woman."  I ASK YOU: what is it about the South that sentences women to the lesser of emotions, in terms of action.  The woman was a FIREBRAND.  To suit, the author was a man, Harnett T. Kane; the book written in 1952. 

She was no wilting rose/ pitiful petunia.  On page 7 of the book is her written word, moving through time, with imagination and potency:

"I have been through the depth of poverty and sickness...I have known want and struggle and anxiety and despair...As I look back upon my life I see it as a battlefield strewn with the wrecks of dead dreams and broken hopes and shattered illusions----a battle in which I always fought with the odds tremendously against me, and which has left me scarred and bruised and maimed and old before my time.

But I have learned to live each day as it comes, and not to borrow trouble by dreading the morrow.  it is the dark menace of the picture that makes cowards of us. I put that dread from me because experience has taught me that when the time comes that I so fear, the strength and wisdom to meet it will be given me."

And SO: I determine that THIS year, 2014, will be associated with a channeling of that muse, Dorothy Dix.  Dear Dorothy Dix: we have so many problems in NC associated with mental health issues.  Thank you, in advance, for your quiet, solid, potent suggestions.  We'll be getting back to you very soon. 

And so, as re: muses, here is one of my favorite songs about the matter, by Loudon Wainwright III (his father was the famous photographer for LIFE magazine for many decades; his son, Rufus, was a 'tit man' (his dad's term, sorry), and is an openly gay musician.  Last time I saw Loudon was in Atlanta about three years ago when he was amazingly, on the stage, w/ Richard Thompson.  What a funny duo: two tremendously talented men, coming from completely different folk music traditions....

Here's Loudon's Muse Blues:

I went down to the library, you know
The big one way downtown
I went down to the library
You know the big one way downtown

I pulled out my spiral notebook
And my Scripto pencil
These are the words
I did put down

I'm a dud firecracker, I ain't got any fuse
I ain't got no inspiration since I lost my muse
I'm a table with two legs, I'm a spider with five
I'm going down, slow muse, when will you arrive?

Oh muse, where are you?
Oh muse, where are you?
You know I eat, drink and I smoke stuff
I don't know what to do, I don't know what to do

Went to the mountain and the desert too
I was there, ladies, so where were you?
I'm a flattened out wave, I ain't got any curl
I'm an empty old oyster, I ain't got any pearl

Muse, where are you?
Oh muse, where are you?
You know I eat, drink and I smoke stuff
I don't know what to do

Sit up late, stay up, wait
That's a rule of thumb, she's got to come
Sit up late, stay up, wait

I take lots of cold showers and I go for long walks
I wait for a pitch but the fickle bitch barks
Took a shot of whiskey and a snort of cocaine
Opened up my head and stuck electrodes in my brain

Oh muse, where are you?
Oh muse, where are you?
Yeah, I eat, drink and I smoke stuff
Eat, drink and I smoke stuff
Eat, drink and I smoke stuff
I don't know what to do
Read more at http://www.songlyrics.com/loudon-wainwright-iii/muse-blues-lyrics/#p4qUU3rb52lxsGrX.99

Sunday, November 10, 2013

NC Psychological Associations: No Mention of Public Mental Health Issues

From: Marsha V. Hammond, PhD, Licensed Psychologist NC

Dear Susan Hill PhD, North Carolina Psychological Association, Mountain Representative: 

Thanks for your hard work as the rep for NCPA for the "Mountain Region."  I just received the November/ December 2013 news letter and I have some comments: 

You indicated that the Executive Director of NCPA, Sally Cameron, is a 'mover and shaker,'  Prove it as re: public mental health.  

Sally Cameron, IMO, is no 'mover and shaker'; indeed, the woman has nothing at all to say, that is useful, re: public mental health e.g., Medicare/ Medicaid.  Twice I have joined NCPA and twice un-joined re: complete lack of attention to public mental health e.g., Medicaid/ Medicare.  I am not suggesting that she be the only person carrying the public mental health 'ball' but I hear/ see/ smell no information from any direction from NCPA re: public mental health.  

To suit, these are some of the pressing problems at this time: 

If one bills 96152, the Health and Behavior codes e.g., 96152 series which APA put into place vis a vis Medicare in 2000-----as of 1.1.2013 (yes, I have talked on the phone w/ Diane Pedulla at APA re: this matter and basically was suggested to "take it to your state org" which is dysfunctional re: public health matters) there is no wrap around to Medicaid under Smoky Mountain Center LME----which is managing Medicaid for about one-fifth of all of NC counties since the collapse of Western Highlands Network LME.  Forget even talking about the thankfully moribund Western Highlands Network LME.  

There is a class action lawsuit around this matter and other non-payment of Medicaid items.  I don't know all the details about that as I am too busy working.  However, Paul Tax, who is over claims at SMC simply had the suggestion to pursue the matter in this way.  

Dr. Bert Bennett, a psychologist at DMA, has no useful information on this.  I have used him as a person who knows what is going on re: these kinds of issues in the past but have no info forthcoming about this lack of wrap around which was formerly in place prior to 1.1.2013. 

That the state psychological association and WNCPA do not even have this on their written radar----as per the WNCPA newsletter-----is perplexing. There was nary a mention of SMC LME or WHN LME collapsing or any other public mental health concerns in the November/ December, 2013 newsletter.  

NCPA and WNCPA are not social clubs for me.  Rather, they should be a place where work should be getting done.  

But that's just my opinion.  Pass this to anyone you like.  

Marsha V. Hammond, PhD, Licensed Psychologist, NC

cc: Irene Matiatos: drirenem@gmail.com
Sally Cameron, NCPA
Paul Tax, Claims, SMC LME
Diane Pedulla, PhD, APA
Bert Bennett, PhD, DMA NC

Friday, August 09, 2013

NC Medicaid 'forgot' to Include Wrap-around Codes to Medicare When LME's took over Medicaid Management


Marsha V. Hammond, PhD, Licensed Psychologist, NC

Address: ______________________ cell: 828 772 5197


NC Mental Health Reform blogspot: http://madame-defarge.blogspot.com/

                                                 Date: August 9, 2013

RE: NC Medicaid ‘forgot’ to include wrap around to Medicare CPT 96152, Health &          Behavior code, for psychologists, when LME’s took over management of Medicaid 1.1.2013

Dear Dr. Diane Pedulla of the American Psychological Association Practice Directorate:

I am writing to you  about a very pressing practice matter which concerns NC psychologists. 

Thanks to the American Psychological Association, beginning in 2000, psychologists were allowed by CMS to utilize the Health & Behavior CPT code 96152 which allows more effective integration of health care.  Prior to the LME’s completely managing Medicaid in NC (in my practice area, it is Smoky Mountain Center LME, about to become the largest LME in NC as Western Highlands Network LME is to be incorporated into SMC LME 10.1.2013), this Medicare CPT code, 96152, paid appropriately and it automatically wrapped around to a DIFFERENT outpatient therapy code via NC Medicaid.  There were no payment issues prior to the LME’s taking over NC Medicaid.  For the past 8 years, I have been paid on time and appropriately for my dually eligible clients, those people being insured primarily by Medicare, w/ a wrap-around to Medicaid.

Prior to 1.1.2013, Value Options and HP Enterprises managed authorizations and payment of NC Medicaid.  Since the LME’s have taken over the complete management of NC Medicaid, utilizing a system known as “NC Tracks”, there is no wrap around available.  I have spoken, at length, to people working at NC Tracks.  I spent an hour today on the phone with an employee there, going over the 288 page Medicaid manual and there is NO MENTION ANYWHERE of 96152 ‘cross-walking’ to any Medicaid code: nada; nothing; does not exist.  I received a ‘number’ which creates a complaint which hopefully will be addressed by the Claims department associated w/ NC Tracks/ NC Medicaid.  

Undoubtedly, when the CPT codes changes and when Value Options and HP Enterprises exited the picture---and the LME’s and NC Tracks via NC DHHS took over the management of NC Medicaid, the ball was dropped re: including the wrap-around for psychologists re: this Medicare code, 96152.  As I stated, prior to 1.1.2013, NC Medicaid AUTOMATICALLY CHANGED THIS OUTPT CODE in order to facilitate wrap-around.  I do not have my old Remittance paperwork indicating what I was paid and since there is no more HP Enterprises or NC Webclaims, where I could view the information online, I cannot pass that to you.  All I can tell you is that the employee at NC Tracks and I were startled to find out that there was so little mention in the NC Medicaid 288 page manual re: psychologists.  That should have been addressed by NCPA, IMO.

Please do not advise me to contact NC Psychological Association.  I already have. Many times over the past 13 years I have complained loudly about the lack of involvement of NCPA re: public mental health e.g., Medicare/ Medicaid.

Today  I left Executive Director Sally Cameron (ncpasally@mindspring.com) a very clear message.  I have joined and un-joined NCPA twice over the past 13 years as they pay no attention to public mental health.  If you have any leverage re: NC Medicaid via NCPA, perhaps you could utilize that. I know that Dr. Tony Puente, who lives in Wilmington, NC, has done a great deal of work re: psychologists’ reimbursement vis a vis CMS (as well as his colleague George, whose Greek last name I cannot spell).  Perhaps you can pass this to him or another pertinent party. 

Every practice day I utilize the appropriate 96152 CPT code.  Every day psychologists in NC undoubtedly use it.  Why? Because it pays at the 80% ‘medical rate’ and because it is an ‘integrative’ CPT code, if you will.  Doctoral level psychologists, such as myself, do doctoral level work and that includes integration with primary care practitioners, etc.

I am looking forward to hearing some information about this.  Feel free to pass this to any pertinent party.  Thanks for your hard work over the years.

Sincerely,

Marsha V. Hammond, PhD, Licensed Psychologist, NC

Cc: Sally Cameron, Executive Director NCPA; Mr. Tax, Claims Director Smoky Mountain Center LME; other employees associated w/ Claims at SMC LME

Bert Bennett, PhD, Psychologist (Behavioral Health Division NC DHHS)