TRUMPCARE and Mental Health/Substance Abuse Coverage

One has to wonder with the recent state of affairs in our political environment where does MHSA coverage stand in all this. As we all watch closely to determine whether all the advances that we have made over the years will all be rolled back to the 1980’s time warp where Mental Health and Substance Abuse were taboo and not always covered under Group benefits forget the individual policies who most times did not even offer this coverage?

So where are we now? Well according to my estimation, if it does not pass the senate then we are still where we have been since 2009.  For those of you who follow this Mental Health Parity and Addiction Equity Act were enacted in 2008.  Teddy Kennedy sponsored this.   This provides for equal treatment of these services in all group health plans with more than 50 employees.  When ACA was implemented, this language was adopted for individual policies as well.    It also mandated that the minimum requirements for an insurance policy must include coverage for MHSA.  Now we are in jeopardy of losing this last part.

So if I am reading the score card correctly individual policies that are purchased can leave out MHSA coverage and we are back to the 1980’s where folks do not even know they do not have the coverage and the insurance companies are telling us the insured opted not to have that coverage.   The average citizen is purchasing an insurance policy based on premiums.  Some are well informed enough to understand all the implications of the benefits but most do not.    Therefore, to that end folks the future is just waiting and see because you can neither predict or determine what is going to be.

We could go on but the other part of this is those folks that want Medicare for All.  We could discuss this all day and I am still not sure what the best outcome will be.

Coding by Duration

Recently a clinician told us that providers had been audited for the use of 90837. The CPT codes have a duration associated with them and if the notes and the duration meet the criteria there is no reason for insurance companies to audit or for you to be afraid of utilizing that code. Most sessions go longer than 45 minutes, which is the CPT definition of 90834, and although in the crosswalks provided, back in 2013 they said that 90806 translated to 90834 they were incorrect.  The 90808 was supposed to translate to 90837 however, the 90808-code definition was 75 minutes or longer which does not equate.

The APA put out a guideline some time back regarding the durations for 90832, 90834 and 90837. Here is the guideline as proposed by the APA:

16-37 minutes use 90832

38-52 minutes use 90834

53 or more use 90837

In addition there are at least two insurance companies that we know of that do not allow the 90837 unless an authorization is obtained.  They are Optima/Sentara out of Virginia and Optum/United Behavioral.   After some research we noted that Optima had a published  allowable for 90837 which makes one wonder if this rule has been relaxed.    (The original rule was regarding the 90808 code for Optima/Sentara. )

For a fact the Blues in most all states allow the 90837 as does Medicare no questions asked.  Most of the insurances we have dealt with through the years do allow this code and there is no specific criteria or red flags.  This makes us wonder if those folks that were being audited also had some other item in their billing that set off red flags with the insurance industry.

Word of caution for all providers you should always ensure that the documentation matches what was billed.  So whether using an Electronic Health Record or some sort of manual system this is as important as the records maintained for the IRS. Keeping these records in synch provides the best method for keeping your practice ethical and out of arms way for those auditors.

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Large Deductibles and Co Pay Tips

Large Deductibles can be resolved in a couple ways

In our business we get asked how to deal with a client that has a large deductible.  Our responses are listed below.

  • Client can waive usage of their insurance
  • The provider may charge the client and expect to be paid the allowable or some portion of that until the deductible is satisfied.
  • If under contract with the insurance company it states that you may not charge the client more than the allowable not that you have to collect it.
  • If in a group the client can be assigned to a non contracted provider with that insurance.  Then the client may be put on a  sliding fee.
  • If out of network with the insurance the client may be charged the standard fee and the client may go elsewhere or decide to pay for that service in full.

Co Pays

With a lot of non profit agencies they struggle with how to work with co pays when the client states that they cannot afford to pay 60.00 per session.  If this is an in network provider than the contract says the client must be  charged the co pay.  It does not say that the client must pay the co pay.   So keeping this in mind what we often advise our groups is that which is stated above.  The client must be charged the co pay, a negotiation may be made with the client to accept a lesser fee and write off the difference.  The client ledger must show the 60.00 charge but it is not necessary to show a payment of 60.00.

Words of Caution

Always keep in mind that often the allowable for a service may only be 60 or 65 so that co pay may be the only reimbursement.   There are a number of Aetna policies out there with a 70.00 co pay.  Master’s level providers allowable is almost always less than that.  So the best bet may in some cases be not to use the insurance but to negotiate with the client for a reasonable fee.   Be mindful of the allowable whether  in network or out of network when co pays or deductibles are involved to ensure that you get the reimbursement you deserve for the clients you serve.

**Medicare deductible is a different animal and it is only 183.00 for Part B.  The advice is not to charge the client the deductible and wait for the explanation of benefits to come back before pursuing this with your client because they may have a secondary that picks it up.