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.

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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.


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Medicare Part B Deductible 2017

It has been announced that the new fee schedules for 2017 are ready to be downloaded but on all the websites we visited there has been nothing about the new 2017 Part B deductible.   This was only announced on the CMS website for 2017 which is funny that all the other intermediary websites don’t think we need to know.  The deductible like everything else except reimbursement has gone up to 183.00 per calendar year.  Also noting that the premium for Part B has gone up but our Seniors cannot get a COL raise.

The new premium minimum is 134.00 per month which is taken directly out of their Social Security Check.   We here at DBMA keep a close watch on those things to try and keep our Providers informed.  We will be downloading and organizing the new reimbursement rates for 2017 in the next few weeks and will announce here when they are ready for delivery.

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CPT Codes and United Behavioral Health

Just in case you are not aware of it this is the only insurance company that requires an authorization for you to use the code 90837.  According to their Medical Policies the 60 minute session is not medically necessary.   You would have to supply a dissertation to get this code allowed.  Any time you bill this code you will get a denial of course unless you have an authorization.

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Provider Enrollment Bottleneck

We provide a lot of Provider Enrollment services to our customers.  Most of this entails submitting the applications for individuals to get them enrolled as providers in the various Networks so that they can provide services to clients with different insurance companies.  In recent months since Humana changed from LifeSynch doing the provider enrollment and credentialing pieces there has been a bottleneck and providers are not getting credentialed for more than 120 days.  You cannot even find out status of a provider request until it has reached 120 days from the time you submitted it.    On another front we are also seeing another bottleneck with Aetna after the providers are approved it is taking anywhere from 30-120 days before the contract is received.    I suspect a lot of this has to do with the mergers and acquisitions going on in the industry and new management taking over.   Provider Enrollment is a tedious mission and the follow up is time consuming.  So this is just a little heads up to let you know what appears to be going on in the Industry.

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PQRS Medicare

Just in case you missed it the latest and last revision to the rules for PQRS are listed below:

Major highlights include:

  • Individual eligible professionals and group practices that meet the criteria for 2016 PQRS satisfactory reporting/participation will avoid the PQRS negative payment adjustment in 2018
  • PQRS group practices can participate in 2016 PQRS via the Qualified Clinical Data Registry mechanism in 2016
  • There are 281 measures in the PQRS measure set and 18 measures in the group practice reporting option web interface for 2016

The 2018 PQRS payment adjustment is the last adjustment that will be issued under the PQRS. For more information about participating in PQRS in 2016, visit the PQRS website.

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Medicare Fee Schedules 2016

Medicare Fee Schedules will be available for 2016 by the end of the week.  Be aware that the new deductible for 2016 is 166.00 for Part B.  Place your order now to get one sent to your office.  Information provided on the fee schedules is by discipline


Medicare Expected

Secondary or client responsibility

The expected amount will differ due to sequestration and PQRS reductions for 2016.     Please do not hesitate to contact us at for your new 2016 Fee schedule.


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Growing Your Behavioral Health Practice with 3rd Party Reimbursement

This book is designed to provide helpful insights into general billing practices for a successful third party billing system for the behavioral health practitioner  and/or Group Practice.   Strategies will be introduced on how to establish and maintain an effective billing system.  Although some steps may not be advisable to the situation in some practices, this book will provide you the reference material needed to assist you in establishing your own third party billing system.  It will provide information about setting up, maintaining and effectively operating a billing system both for the private for profit practitioner and the not for profit practices.

The use of third party reimbursement in a provider practice will differ from practice to practice and it will also differ from client to client.  A provider practice may elect to accept assignment and treat clients on specific insurance panels or the provider may elect to only accept private pay clients.   If a provider elects to only accept private pay it may be necessary for them to create an itemized receipt to provide the client with appropriate information that they can submit to their insurance.  In some instances if a provider is not in network the client will not be reimbursed at all or the deductible will be so high it is not possible for the client to ever reach it.  Either way it is important that the provider be well informed of the choices when establishing the Practice.

There is a need for the practice to be flexible where insurance/third party reimbursement is concerned.  The very survival of the practice may rely on this flexibility.  There will be some clients who prefer to pay full fee and will not use their insurance while others will not be able to afford therapy without using their insurance.  It is good business to have a variety of pay sources that a practice receives reimbursement.

Three major factors come to mind when considering third party reimbursement, client eligibility, service eligibility and provider eligibility.   All three factors have to come into play in order to receive third party reimbursement.

Who benefits from third party reimbursement?  The client, the provider and generally it is beneficial to the community, and the insurance company also benefits.  Now you say how can the insurance company benefit from reimbursement?  It is a proven fact that many times a client seeks the care from their general practitioner for depression and anxiety that may manifest as physical aches and pains.  In turn they run up bills for services that were not, entirely necessary in the diagnosis of the condition.

This is part of the Intro to my book to be published some time in the fall hopefully.  I welcome your feedback.

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Fee Schedules

Medicare Regional Reimbursement Schedules are normally made available every year towards the end of January when all the fee issue shake out.  Every year since I have been doing this there is always a change and a rollback on the Medicare fee schedules.  As soon as those fees are available we update our fee schedules and make these available for you.

You can go and get your fee schedules on the internet yourself or you can subscribe to obtain them from us.  We go a few steps further in figuring out what you should be expecting Medicare to pay and what you should be expecting from your client or their secondary.  Our fee schedules also compute the allowable amount for LCSW’s because that is not published on the internet.  This is a service that you do not have to be a contracted customer with DBMA in order to obtain these schedule.

In addition, we also have other insurance fee schedules available and we have recently added Tricare to our list of companies that we calculate how the coverage will play out according to the Tricare plan the individual is on.   If you are interested in any of this, please feel free to send us an email or contact our office.  We are always happy to serve this community.

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