Friday, April 27, 2012

Why Providers Don't Get Paid When Their Clients 'Switch' Their Medicare Plans: Watch Out for United Health Care company

Watch OUT for this Medicare Advantage Plan: United Health Care  POB 29675 Hot Springs, AR 71903-9675.  If your client switches to this, according to paperwork I recently received from the company denying me ALL payments for sessions since the client switched, this is what has happened according to my very efficient, knowledgeable biller: 

"Hi Marsha -
> The new Medicare option plan that she is now on is denying stating she
> "self-directed out of network".  This plan is BS, folks are told that if
> they switch they can continue working and seeing any Medicare but then when
> the claims are filed - they deny for you not being in their network.  You
> and the client can fight it - tell them you will be contacting the NC Dept.
> of Insurance, etc. but expect it to take a while.  "

Yipee!! More paperwork.  

Why Do 1 in 20 Americans, Ages 25 to 64, Collect Disability?

Many of the people receiving mental health services in NC have Medicare and most (those who have received disability insurance payments after two years, also receive Medicaid).

There's a fascinating article in the NYT April 25, 2012, as associated with the yearly meeting of the trustees of Social Security and Medicare:

*Under Reagan (you know, one of those spendthrift Republicans), "....In the mid-1980's Congress softened the criteria which usually required medical diagnoses.....(and) opened the door for applicants who reported mental ailments...collecting disability became even easier as rejected applicants were allowed to appeal before an administrative judge without anyone from Social Security present to defend its decision....."

*Thus, this became the point in time when people with mental health challenges began receiving a great deal of disability insurance

*Prior to that, it was difficult to get into the program

*When unemployment goes up, applications for disability goes up

* Disability insurance payments account for almost $1 our of $5 spent by Social Security

* This past year, the government paid $128.9 billion to 10.6 million disabled workers, 25 percent mroe than it received from payroll taxes

*On top of that (the Times doesn't say this but I know that these two populations overlap as some of my disabled clients received both SSDI and SSI disability checks every month): 5 million adults receive $33 billion from SSI, Supplemental Security Income

*Medicare spent more than $90 billion on benefits for disabled workers (as a provider, that is where the bulk of my money comes from, those Medicare benefits)

*Medicaid spent $110 billion more on the poor disabled (as a provider, Medicaid is more difficult to manage ,particularly with the advent of this idiot Medicaid waiver being launched in NC, and in particular, as associated with one of the first LME's to utilize this, namely the local Western Highlands Network LME).  I dare say that most of that Medicaid money will have been consumed by the ADMINISTRATION rather than the actual treatment of Medicaid beneficiaries----which will make Medicaid in NC the most inefficient health care of all----far less efficient even than the Medicare Advantage plans e.g., Humana, which are progressively being defunded by the Obama administration given their 15+% administration fees versus Medicare's less than 5% administrative fees.

*The population of disabled adults is growing, particularly for men of all ages

*Disability outlays have grown about 5.6% a year after inflatio in the past two decades compared with 2.2 percent for other Social Security spending

*the Disability fund will be exhausted by 2016, two years earlier than previously estimated (after that, this fund will be supplied by diverting money from older recipients receiving Social Security Benefits

*people living on Disability can earn up to about $1000/ month and retain benefits but only 1 in 10 makes any extra money

*"The good news is that the disability program is easier to fix.  Unlike Social Security and Medicaid, whose financial strains are driven mostly by demographic forces, the disability program suffers from artificial woes that can be corrected.  Fixing the system requires providing incentives to enable disabled workers to continue working if they can..."

And HOW, pray tell, will these jobs be found in a jobless economy----particularly joblessness in rural western NC, where there are fewer and fewer jobs?

Nice work, if you can get it.


Saturday, April 07, 2012

TRICARE / CHAMPUS Enrollment and Billing Information: Just What IS 'Crisis Management' as per TRICARE 90808 billing?

The devil's in the details regarding all this insurance payment brouhaha.

About 6 months ago, a local liason from Buncombe DSS contacted Senator Burr's office on my behalf as I was having such a problem signing up as a provider w/ TRICARE/ CHAMPUS (working with military personnel as a psychologist). Senator Burr's office in Winston-Salem did a good job of following up on the matter. Kyle is the contact person there, in that office.

It is very confusing initially trying to figure out which part of TRICARE a mental health provider---in terms of outpatient mental health-----you apply to. This was true even after I attended an Inservice in Asheville at MAHEC put on by TRICARE.

To apply to TRICARE as a providerHalthNet Federal Services (HNFS) is the Managed Care Support Contractor for TRICARE's North Region. Providers should visit the following site to sign on: or call 1 800 541 3353.

First of all, NC is in the Northern region of TRICARE. Therefor, the North Region manual is what should be attended to:

Here is information back from Michael O'Bar, Deputy Chief, TRICARE Policy and Operations, Office of the Assistant Secretary of Defense Health Affairs, Skyline Five, Suite 810 5111 Leesburg Pike, Falls Church, Virginia 22041-3206.

TRICARE has no policy for a 50 percent mental health rate according to Mr. O'Bar. That is the reason why mental health providers avoid the 90806 (usual psychotherapy series of payments) when they can. In other words, there appears to be at least some mental health care parity as concerns TRICARE, unlike with Medicare. Go figure.

Overall, TRICARE pays at about the same rate for 90806 as Medicare does for the CPT code series 96152, Health & Behavior codes (if you want to stay alive financially, a provider has to learn how to apply the CPT codes so that one is maximally paid for one's work).

The H & B codes pay at the 80% Medical rate versus the psychotherapy series, 90806, 90808. For physician/ non-facility pay that would be about $95/ session for a 90806 under TRICARE----significantly better than Medicare due to its 50% mental health rate (discrimination: yes what did happen to mental health parity; Medicare never paid attention to it).

The Health & Behavior CPT codes were put into place by the American Psychological Association in 2000 (the 96152 series bills in 15 minute increments; it pays at the medical 80% rate versus the 50% mental health rate as regards Medicare----never use 90806 or that series if you can help it).

The American Psyc hological Association outlines what it believes to be pertinent in order to utilize the H & B codes. For instance, in my Notes kept on clients, I put in templated information so that if my records are called forward, it is obvious that I have been in correspondence w/ medical providers and that I am paying attention to medically-oriented issues such as medication and health matters. (Many of the clients I see have overlapping mental and physical health issues).

One of my questions to TRICARE vis a vis Senator Burr's liason, Kyle, was this: is 90808 (70-90 minutes psychotherapy) a 'stable' CPT code (I not infrequently have 1.3 hour sessions w/ clients). In other words, if I use 90808 for billing, will I reliably be paid for it? ----versus the 90806 which is the more standard and commonly used 45-50 minute session (where in the world did that come from, anyway?)

TRICARE will pay at the physician rate/ non-facility $128.95 (90808). For non-facility/ non physicians the rate is $96.72.

Relatedly, Mr. O'Bar stated in his letter to Senator Burr that as per my question as to whether 90808 'is a stable code' (read: can you bill it time and again like a 90806 or 45-50 minute session) that, "The TRICARE Policy Manual, Chapter 7, Section 3.13, regarding psychotherapy ( provides that benefits are available for inpatient and outpatient psychotherapy that is medicall or psychologicall necessary to treat a covdered mental disorder. The policy also lists coverage of CPT 90808 FOR CRISIS INTERVENTION...."

So, I googled up that information and this is what I see, which is not much help:


3. Crisis intervention (CPT2 procedure codes):90808 - PSYTX, OFFICE, 75-80 MIN90809 - PSYTX, OFF, 75-80, W/E&M90821 - PSYTX, HOSP, 75-80 MIN90822 - PSYTX, HOSP, 75-80 MIN W/E&M

So, my question: is there a limit to 'Crisis Intervention' and what is the definition of that? I ask that as a whole lot of therapy is associated with 'Crisis Intervention'-----at least in my practice.

So, I looked some more and google took me to Humana TRICARE (is Humana handling TRICARE, I wonder?):

"The following outpatient psychotherapy coverage limits apply:

Psychotherapy: two sessions per week, in any combination of the following types:
Individual (adult or child): 60 minutes per session; may extend to 120 minutes for crisis intervention

Family or conjoint: 90 minutes per session; may extend to 180 minutes for crisis intervention
Group: 90 minutes per session...."

Not more information there other than you can have 2 sessions/ week and that 120 minutes must somehow be discriminated (how? is there a modifier on the billing? or is it just as related to the Notes that the psychologist keeps that speaks to the matter of 'Crisis Intervention'?)----so I found the Northern Region manual which is here (NC is in the northern region, remember):

Starting on page 55, it outlines behavioral health:

1. There are, as w/ NC Medicaid, 8 self-referred non-managed visits.

2. There is a telephone number that TRICARE insured folks can call (if you're a provider, you would want to make sure your name is linked to that and how that happens I do not know): "....877-747-9579, is available to eligible beneficiaries from 8 a.m. to 6 p.m. Eastern Time (7 a.m. to 5 p.m. Central Time), Monday through Friday, excluding holidays. ..."

I don't see anything, anywhere about the meaning of 'Crisis Management' and I might speculate that if one submits a 90808, you are going to be asked for records and given the run-around.

THEREFORE, here is my letter to Mr. O'Bar w/ a cc to Kyle at Senator Burr's office.

"April 7, 2012

Dear Mr. O'Bar, Deputy Chief TRICARE Policy and Operations:

On my behalf, thank you for your correspondence w/ Senator's Burr's office regarding my questions associated with the usage of CPT code 90808. You stated:

"The TRICARE Policy Manual, Chapter 7, Section 3.13, regarding psychotherapy ( provides that benefits are available for inpatient and outpatient psychotherapy that is medicall or psychologicall necessary to treat a covered mental disorder. The policy also lists coverage of CPT 90808 FOR CRISIS INTERVENTION.." (caps are mine).

I am afraid that nowhere in the North Region manual, from page 55 on, as associated with Behavioral Health, is there any description of what 'Crisis Intervention' is.

My question is this: if I have a veteran, recently returned from combat, who requires multiple 'Crisis Intervention' therapy sessions, which, as I understand it can be up to 2/ week, am I going to be required to ask for authorization to use 90808 multiple times? Am I going to be turned down reimbursement if I utilize 90808 more than one or two times? How many times of usage of this code over a fiscal year is possible? What is the criteria for the usage of 'Crisis Intervention' as associated with the CPT code 90808?

I find that longer sessions are more useful than 45 minute sessions, basically, and that is why I am asking questions about this 90808 CPT code.

In that I cannot find any description of what 'Crisis Intervention' is in the North Region manual, or if it has a special modifier as associated with billing, I am hesitant to use the code which could certainly be applicable in such situations.

I try to be efficient in my practice and not spend time correcting billing mistakes which I could have anticipated.

Thank you for further information on the use of the 90808 (70-90 minutes psychotherapy) CPT code as associated with 'Crisis Intervention.' It appears to me that a 90808 is ALWAYS associated with Crisis Intervention as re: TRICARE. Is this true? I would appreciate some more detail information on this matter.

Thank you so much for your kind assistance.

Marsha V. Hammond, PhD, Licensed Psychologist, NC"

Value Options Approved 44 Outpatient Therapy Sessions Thru Remainder of Year: What is the Purpose of the V.O. 'IN' Box??

The client of which I spoke in a just previous post, who I had been seeing for over 6 years, a matter which merited an initial refusal of Value Options (V.O.) to pay for continued visits-----was approved for 44 sessions thru the remainder of 2012.

Bear in mind that V.O. is the private company that is the spokesman for NC Medicaid outpatient therapy authorization-----or any Medicaid authorization. If you are not authorized by V.O., you will not get paid. NC Medicaid providers are provided with a secure link in order to communicate w/ V.O. We must submit all ORF2 forms (the form which allows a provider to be paid after the 8 sessions/ calendar year) via this link. Supposedly, V.O. reciprocates and communicates with US via this link. Ya think?

When I asked the Value Options woman who spoke to me about this matter----as I had received no paperwork (a route formerly utilized by V.O. to communicate w/ providers) after a couple of weeks about the matter---and neither was there any information in my "IN" box as associated with being a Value Options provider----said that as far as she knew, I should have received an OK in my "IN" box.

Whatever else is the reason for the "IN" box at the Provider URL for Value Options if not this?

Chalk up one more barrier to care for NC Medicaid patients: the provider is not even sent efficient notification as to whether s/he will continue to be authorized/ paid to see a client when the ORF2 Form is sent to Value Options (requesting authorization after 8 outpatient mental health care visits).

Nooooo: you have to call them time and time again. And they can't even tell you why the information is not in the "IN" box.