Let's talk turkey: what the clinical doctoral psychologist gets paid to see clients

There was a suggestion that providers are making so much money that they are able to construct buildings (!).

What I see is providers seeing clients in their homes; renting office space for cheap; obtaining funding for office re: the United Way.

I believe it is very important for people to talk about money. The non talking of it allows the payors to screw the payees.

Let's overview what Medicaid pays. For a PhD psychologist, with 4 yrs of college; 6 years of post-graduate training, for 90808 CPT code (70-90 min therapy), wherein the psychologist goes out to the client's home, utilizing modifier codes of AH and AQ (clinical psychologist; impoverished area of service), the pay is approx $136.00. What is usually billed is for $150.00 in that it is in keeping with Medicaid/ medicare outline as legitimate for a doctoral psychologist. That does not include the co-pay. No medicaid client has a co-pay. Its either eat or gather up the co-pay. Most psychologists would only bill for 90806, 45-60 min of therapy, as to bill for the 90808, I'm told, is to risk audit.

Now duh: why do I see my clients in their homes? A no show client is a non-billable client. This is not the private, for-fee world that people seem to think exists.

Bear in mind that private insurance follows suit in terms of what they will pay----always looking to see what Medicare and Medicaid are doing. You then get some idea why psychologists go into forensic work, so they can get on the stand and bill for what they should be paid (and then some).

Let's overview what Medicare pays. Medicare pays 62.5% of the above CPT code. However, if you have a client who has medical issues, and these are outlined in the notes, the psychologist or social worker may use 96152, Behavioral Health CPT code. That pays at the medical rate of 80%. That means for the 90808 you get .80 x 150 or 80% of the 150.

Let overview what state funded clients pay----which is very grim indeed. These are the clients who cannot obtain Medicare or Medicaid; these are people w/o children, over 21, and under 62. Yes, they can file for social security disability, wait for that to go through for 2-3 yrs; get an attorney who for the life of the social security disability takes a percentage----- and then if they don't get too much social security disability (more than 600-700$$/ month in Social Security Disability), they can get access to Medicaid. Otherwise, they hit the 'doughnut' and cannot get to Medicaid which overlaps with Medicare. Medicare is always billed first.

Shall I tell you how long it took me to figure out how to use Medicare Claims Express 3.2, interfacing with dial up modem vis a vis EDI? There's no pay for that.

I digress: for CPT code 90808, wherein the clinical doctoral psychologist goes to the client's home, has therapy with the client for approx 1.5 hrs., bills the LME under Community Support restrictions (modifier codes don't matter: you could be 100 miles inj the sticks w/ no transportation and there would be no modifiercodes) you obtain authorization at 90808 but the LME then morphs the code into something that allows them to pay you approx $92. That's almost a 50% loss of fee.

You take it off your income taxes at the end of the year as a loss. I haven't tried this before but I'll be doing this time around.

Come and get me IRS.

DHHS: incompetent to the core

Like I said: DHHS appears incapable of handling mental health reform.

They have effectively defunded Community Support Services (which includes emergency services); they have 2/ 4 NC state public/ main psychiatric hospitals under investigation (Broughton Hospital; Cherry Hospital); and, three of the key people, for better of for worse, have left (plugging into mutually back-scratching jobs: Allen Dobson; Hooker Odom; Mark Benton).

And now we hear that the director of Cherry Hospital is a physician whom, quite some time in the past, 'took indecent liberties with a child.' If this is true (we would like for the journalists to let us know some more details), you can bet that this physician worked hard to diminish the charge and that a less well funded person might have been put away. The details of that case would be a real eye-opener, I bet.

"Owens (Medical Director of Cherry Hospital; eastern NC mental health hospital) has a 1989 conviction for taking indecent liberties with a child."

http://www.witntv.com/home/headlines/9739662.html From WITN-TV, Eastern NC:
Cherry Hospital Doctor Reassigned

NC Mental Health Reform: corporate welfare flying under the radar

Two interesting recent ‘announcements’, one from the Federal Register, and one from the ‘non-profit’ NC Council on Communities’ newsletter, remind us of just how far we have NOT come----in terms of transparency and commitment to truly assisting people with mental health issues.

Carmen Hooker Odom, (still) current director of NC DHHS, has been on the board of Carolinas HealthCare System as has her husband, Fountain Odom. At DHHS, directly under Hooker Odom, has been Alan Dobson, Assistant Secretary for Health Policy and Medical Assistance for DHHS, and Mark Benton, Director of Medical Assistance.

Utilizing a chirpy tone of ‘we wish them well’, The NC Council on Communities newsletter announces that Dr. (Alan) Dobson (Department of Medical Assistance key administrator under DHHS) will return to his medical practice Cabarrus Family Medicine which is merging with Carolinas Health System (Carolinas Health System is run by Hooker Odom's husband & Hooker Odom has served on its board: Hooker Odom, Secretary of the Department of Health and Human ... also served as the group vice president for Carolinas HealthCare System (CHS), www.governor.state.nc.us/News/PressReleases/Attachments/cabinet.pdf. Mr. Benton, according to the newsletter, “is leaving his position to join Carmen Hooker Odom at the Milbank Memorial Fund in New York city(sic)”

The notion of "the more things are different, the more they are the same" didn’t come from nowhere.

The Federal Register document, outlined how North Carolina DHHS ‘chose’ a ‘rehabilitation model’ pertaining to the overall guide associated with mental health care, amongst the undoubtedly glamorous array of choices offered by the US Department of Health and Human Services, under Bush.

The Federal Register not of August 13, 2007 (Volume 72, Number 155) states: “New rules for Rehabilitative Services under Medicaid were recently published in the Federal Register. North Carolina’s new State Plan is under the Medicaid Rehab Model.”

There has been some talk on the NCAdvocacy (mental health consumers and providers) listserv about the drawbacks of having a ‘rehabilitation model’ when mental illness is commonly a chronic illness that can be partially ameliorated by good mental health care.

Under Item, “C. Written Rehabilitation Plan”, we are advised: “In all situations, the ultimate goal is to reduce the duration and intensity of medical care to the least intrusive level possible which sustains health.” Under the Bush neoliberal administration, government is thus framed as being ‘intrusive’ and as something to be done away with, rather than a tool to access one services on the merit of having paid taxes all one’s life.

Overviewing David Harvey’s book, A Brief History of Neoliberalism,in the British paper, The Guardian Weekly (31.08.07, p. 18: http://business.guardian.co.uk/comment/story/0,,2157199,00.html), George Monbiot, makes the following point: “The conditions that neoliberalism demands in order to free human beings from the slavery of the state---minimal taxes, the dismantling of public services and social security, de-regul;ation, the breaking of the unions----just happen to be the conditions required to make the elite even richer (to swap jobs amongst each other: the names are the same) , while leaving everyone else to sink or swim.”

The Federal Register document (continues): “The rehabilitation plan would also document that the services have been determined to be rehabilitative services consistent with the regulatory definition, and will have a timeline, based on the individual's assessed needs and anticipated progress, for reevaluation of the plan, not longer than one year…... If it is determined that there has been no measurable reduction of disability and restoration of functional level, any new plan would need to pursue a different rehabilitation strategy including revision of the rehabilitative goals, services and/or methods. It is important to note that this benefit is not a custodial care benefit for individuals with chronic conditions but should result in a change in status. The rehabilitation plan should identify the rehabilitation objectives that would be achieved under the plan in terms of measurable reductions in a diagnosed physical or mental disability and in terms of restored functional abilities.

We recognize, however, that rehabilitation goals are often contingent on the individual's maintenance of a current level of functioning.

**********(here’s the head twister): In these instances, services that provide assistance in maintaining functioning may be considered rehabilitative only when necessary to help an individual achieve a rehabilitation goal as defined in the rehabilitation plan. *************

.... Services provided primarily in order to maintain a level of functioning in the absence of a rehabilitation goal are not rehabilitation services.”

So, here's the bottom line: if you have a mental health condition, you have to get back to some previous level of satisfactory functioning for if you stay the same or deteriorate, your Endorsed Provider will simply have to create more paperwork, outlining yet another plan of rehabilitation, causing the client to shift to another way to get 'rehabilitated.'

But HEY: that's why we have the congenial 'Person Centered Plan' with the PLAN being that the consumer or client have the illusion of being in control of what is taking place.

Monbiot, of The Guardian article, explains: "The corporations' tame thinkers sell the project by reframing our political language. Nowadays I hear even my progressive friends using terms like wealth creators, tax relief, big government, consumer democracy, red tape, compensation culture, job seekers and benefit cheats. These terms, all promoted by neoliberals, have become so commonplace that they now seem almost neutral."

The very term, Person Centered Plan, is utilized in order to lull the consumer/ client/ provider into thinking that something positive is taking place----THAT THEY ARE IN CONTROL OF----when in fact, they are not, if it fails. And if it fails, all of one's 'rehabilitation plans', then why, it must be the fault of the consumer.

Right?

I don't think so.

http://www.guardian.co.uk/Columnists/Column/0,,2161942,00.html

Monbiot comments the next week in The Guardian Weekly:

"This great free-market experiment is more like a corporate welfare scheme

After my column last week, several people wrote to point out that the neoliberal project - which demands a minimal state and maximum corporate freedom - actually relies on constant government support. They are, of course, quite right. The current financial crisis, caused by a failure to regulate financial services properly, is being postponed by government bail-outs. The US federal reserve has reduced its lending rate to the commercial banks, while the Bundesbank organised a €3.5bn rescue of the lending company IKB. This happens whenever the banks suffer the consequences of the freedom they demand. ..."

The rich get richer and the mentally ill have an endless parade of rehabilitation plans. (I knew I should have studied my economics better).