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.

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.

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.

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.

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.


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.

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.

Who’s Who?

Who’s on first?  This is my new saying as I try to work with the different insurances only to find out they have been bought by one entity or another.  Recently I was invited to go to a meeting in Houston and the speakers were going to be Beacon Health Strategies.  When asked who they were I remarked I think they bought PsychCare.  I was right but they also bought Value Options and although I think the two will maintain their names for awhile they pretty much have shut down the PsychCare website where I used to check eligibility on Humana clients.  We were having to call which is a big hassle trying to get through to the right place at PsychCare because you have to be intuitive to know which number to choose to get to Eligibility and Benefits because it is not an option.  Pet peave.  Always has been for me that the choices with the IVR do not include Benefits and Eligibility.  But I digress.  In addition Coventry bought MH Net last year or maybe the year before and Aetna bought Coventry so they are all operating with the different names but when you dig deeper you find that the credentialing is all done by Aetna.  Payments still come from the different entities. We keep trying to stay ahead of that ball to make sure our claims and credentialing information go to the correct place.  It is always a challenge.

Transition from ICD9-ICD10

This was in a newsletter from ValueOptions and I believe it responds to an age old question I have received for many years as to why Clinicians are taught in school to diagnose with DSM when the standard for billing has always been ICD.

Both DSM and ICD codes are used for diagnosis, but per HIPAA, ICD must be used for billing purposes. DSM-5 utilizes ICD-9-CM and ICD-10-CM coding depending on the date of service. The move from ICD-9 to ICD-10 is a rather large change. Some highlights include:

  • · The number of characters are increasing from 3 to 5 characters to 7 characters
  • · Codes can be alpha or numeric on any character
  • · The number of codes is growing from approximately 14,000 to 69,000 codes
  • · The concept of one to many is introduced with the possibility of a single ICD-9 code now having multiple ICD-10 codes and descriptions
  • · Some concepts will be retired – an example is substance dependency where dependency is replaced by use and specific substances are documented vs. polysubstance

Overall, by using ICD-10, documentation should improve

Claims Implications

For purposes of claims payment, the correct ICD diagnosis coding should be utilized based on the date of service. For dates of service prior to October 1, 2015, the ICD-9 coding format should be utilized. For dates of service October 1, 2015 and later the ICD-10 diagnosis coding should be the format utilized. Claims will need to be split between these two dates if submitting for a range of dates.

This applies to all claims regardless of the method of submission.

In Addition, I found this little crosswalk that I thought might be useful.  For more information on this, contact our office at 877-891-9352

Co Pays Coinsurance and Deductibles

We are often asked this question about Co pays, Coinsurance and Deductibles.  We must talk on this topic at least 5-10 times a week to one customer or another.

1) Can you charge the client less than the co pay?

The answer is No you must charge the client the co pay on your ledger but what you accept is between you and the client.  If you are contracted with an insurance company the specific wording in your contract says that you may not charge your client more than the allowable or expect them to pay more than the allowable.  It does not say you cannot accept less than the allowable.  Be aware of what your allowable is for a specific service and do not shortchange yourself.  For instance many times I find that the co pay exceeds the allowable.  So your client comes to you and says I cannot afford 60 per visit so you slide it down to a more reasonable amount for this client and then the insurance comes along and applies all to the co pay and you get whatever you got from the client.  This is something I try to help our customers be aware of when we do the verification of benefits.

2) What is the fee for this client when the client has a coinsurance?

Co pays are a flat amount each service, but coinsurance is a percentage of the allowable for that service.  This amount will differ from service to service.  If you do 45 minutes or 60 minutes the coinsurance amount will change so you can’t set a flat amount for each service unless you intend to do the same service each time.   You must show on their ledger that you charged them the correct coinsurance and no more.  Again what you decide to accept as payment from your client is your business.  The accounting just needs to show that you did indeed charge them that amount.

3) How should I handle the deductible?

Here is the problem with deductibles,  other providers can meet that deductible it is not just your practice.  Be aware if your client is going to other types of providers because if I was to tell you that it will take 10 visits @60.00 per visit to meet that deductible it may take less because the client has seen another provider for a different service and it has been applied to their deductible.  Again if you are contracted with this insurance you do not want to charge the client more than the allowable until they meet that deductible.  If you are not contracted with the Insurance you may charge them your full fee.

These items tend to trip providers up a lot and we try to warn our customers against charging a customer a flat rate to meet the deductible it may be better to take a percentage of the allowed amount and advise them that once the claim has been processed by the insurance there may be a difference that they will be responsible for at a later date. Or you may choose to eat that it is entirely up to you.   Some of our customers use this method if the deductible is less than 1000.00 they will charge the client 50% each visit until deductible is met and if it is more that 1000 but less than 2500 they will charge the client 70-80% your choice until that deductible is met.  If more than 2500 then they charge the client 100%.  But of course it is your practice you can decide which way to do it.  Your billing person should advise you when the insurance starts paying and the client fee can be adjusted.