Well, this is reminescent of what is taking place re: Medicaid clients under Western Highlands Network LME which manages many of western NC counties, including Buncombe county, where Asheville is. I have had to send in a request to request getting on the provider network. And that takes days, or weeks....and so we go round and round...every single mental health provider regarding inability to get authorization so we can get paid to see patients.
This is the situation re: Tricare which insures veterans. This is my letter to MHN, Mental Health Network, which credentials and sets the reimbursement rate for providers. This is only the initial letter . There's pages and pages to be filled out after this...and months and months to wait....
FROM: Marsha V. Hammond, PhD, Licensed Psychologist, NC
Mailing address: NPI: 1194700591
TO: Michelle Barselo, Manager MHN, credentialing & reimbursement for in-network Tricare Fax: 1 877 821 8215 phone: 1 800 888 4024, x 4517
RE: recommendation by MHN employee to contact you regarding in- network PhD, Psychologist reimbursement rates and CPT coding
February 8, 2012
Dear Michele Barcelo:
This is a longer letter outlining matters which is being sent to Senator Burr’s office in keeping with his interest in the difficulties of mental health providers being able to work with veterans. I also am sending you, as requested, three separate letters as associated with the three different query items, which you could perhaps present to the Tricare liason working at MHN, which coordinates Tricare reimbursement rates and credentialing. This information is also forwarded to the Practice Directorate at the American Psychological Association with a membership of 150,000 psychologists throughout the US. The Military Psychology Division of APA is also receiving this important information, given that the VAMC trains more psychologists than any other site in the US. I did such training at the Birmingham, AL, VAMC.
Today, after looking at the significantly less than Medicare/ Medicaid reimbursement rates---about 30-40% less---- for MHN in-network contracted doctoral psychologists and Tricare contracted in-network reimbursement for doctoral level psychologists----- in order to work with (my intention) veterans, I recontacted a helpful gentleman at MHN, Gus X. Riddles. Mr. Riddles called me several weeks ago as Senator Burr’s (NC) office had contacted me several months ago related to persistent problems in being able to become in-network with Tricare in order to work with veterans in rural western NC. In that Mr. Riddles advises me that there are a total of
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less than 175 insured parties in Buncombe and Haywood county, where I work, I am not asking about MHN clients but rather about Tricare matters---
-which MHN coordinates----including the fee structure, according to Mr. Riddles.
I would hope that Tricare could at least pay as much as Medicare/ Medicaid but obviously this is not true per the data at the Tricare page (http://tricare.mil/CMAC/
He advised me to send you separate faxes requesting a review/ negotiation regarding these issues which are barriers to providing outpatient mental health care to veterans in rural western NC. As you perhaps do not know, the county in which I do most of my work, Haywood County, has more veterans than any of the other 100 counties in NC. I have been trying to move into becoming a provider with Tricare for at least two years now, having submitted a variety of pieces of paperwork, attended a MAHEC mental health conference in Asheville 2.5 years ago, and having been called by various people, and now, thankfully, stumbled upon the helpful Mr. Riddles through no effort of my own but in association with Senator Burr’s office. I thank you in advance for your kind assistance. Mr. Riddles advises me that up to 30 days are required for you to interface with the Tricare liason. Then it is 30-45 more days when I put in my application in order to be an in-network provider. As I have indicated above, I am a Medicare provider, NC Medicaid provider, a BCBSNC provider, a Humana provider, etc.. I find it extremely disheartening to have to spend a great deal of my time writing these letters and creating this paperwork in order to re-create the wheel time and again. If NC Medicaid was not collapsing, I would not be trying to become in-network with Tricare.
These are the three areas outlined which are problematic regarding the 70+ page contract which Tricare, via MHN, who handles the credentialing and fee structure for Tricare, that I have noted. This request here is submitted prior to even submitting the 10+ pages of paperwork being requested by MHN and is even in addition to the CAQH ‘attestation’ pages which is required and which has all the information about my license, etc., online.
Specifically, these are the issues and I will create three more letters faxed to you in order that you could perhaps present them to the Tricare liason:
(1) as a general point, the doctoral level rate at the Tricare TMAC
reimbursement rate site is the same as the master’s level rate. Given the
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severity of the issues of returning veterans and the extent of my training
clinical/ health psychology training which includes an internship at the VA in
Birmingham, AL, I would like to maintain that a doctoral level psychologist
be paid more than the master’s degree person. All doctoral level NC psychologists have such training though a modest number train at the VAMC. The master’s level practitioners are not psychologists; they may be Licensed Professional Counselors or in NC, one of about five states, the master’s level people are supervised by the doctoral level people. I realize this is a bigger issue than can perhaps be taken into account regarding my own contract but I want to put this out there so you understand the difference between a master’s level mental health practitioner and a doctoral level psychologist that can provide assessment and more in-depth and thorough outpatient treatment.
(2) Many clients benefit from an extended therapy session, specifically, 70-90 minutes. This would particularly be so since I see many of my clients in their homes and transportation is a very significant issue in rural western NC where there is mostly no public transport. Also, I am not willing to travel to see someone for a 45 minute session. And so, is there a code that would increase the psychologist’s reimbursement re: the rural area and in-home? I also would suggest that when someone is utilizing therapy in order to overcome PTSD (documented one-third of returning veterans) and perhaps associated closed head injury trauma, that an extended session is recommended. I have enough experience now to be wary of my initial request for these longer sessions, a CPT code associated with 90808---given that insurance companies balk at using this code. Is this a ‘stable’ Tricare code?
(3) Most importantly, as regard how I maximize my billing and
reimbursement via Medicare/ CMA, at the Tricare website, the reimbursement for a ‘non-facility, non-physician 90808, 70-90 minute session is $96.72. I do not like to use 90808 as this CPT code pays at the undesirable 50% mental health rate (yes: mental health, regarding of all the talk about parity, is paid at 50% of the ‘Total Maximal Allowable Charge’ whileas non-mental health is paid at 80%). Therefore, I use the Health & Behavior CPT code series, put into place at Medicare/ CMS (Centers for Medicare/ Medicaid Services) back in 2000 by efforts by the American Psychological Association. This 96152 CPT series bills in 15 minute increments. Medicare pays approximately $25/
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15 minute increment for my service and the Tricare page indicates a pay of $16.25. As you perhaps know, in addition, most Medicare patients have
Medicaid and NC Medicaid picks up what Medicare does not. Thus, dually eligible patients, having both Medicare and Medicaid, have no co-pay. Given the dire economic circumstances which are even more dire in rural western NC, I think you might see the logic of ‘no co-pay’ for veterans who cannot find jobs except perhaps at the local WalMart for $7.25/ hour (yes, I know a 4-tour veteran who is working at the Waynesville, NC WalMart for exactly that). So, as I said, I typically see people for, as I said, the 70-90 minutes. You can see the difference in the reimbursement rate.
I look forward to speaking and/ or hearing from you at your earliest opportunity and thank you for reading this information. Enclosed or attached please find three separate letters associated with each item outlined above.
Marsha V. Hammond, PhD