Are You Getting the Correct Reimbursement for Services?

According to the Institute of Medicine (IOM), primary health care is defined as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

Furthermore, primary health care does not consider mental health separately from physical health, says the IOM. Psychiatrists, like all other primary care physicians, address a large majority of personal health care needs, develop a sustained partnership with patients, and practice in the context of family and community.

One can imagine the surprise, then, when a mental health professional in Southwestern Pennsylvania was told by a contractor that mental health professionals practicing in Health Professional Shortage Areas (HPSAs) are not eligible for the standard 10 percent incentive payment for physicians who render services in an HPSA.

My office, however, played an essential role in disputing that claim, and I am happy to report that psychiatrists practicing in HPSAs are eligible for a 10 percent bonus payment.

The Omnibus Budget Reconciliation acts of 1987 and 1989 established a bonus payment program for physicians who treat Medicare patients in HPSAs. Section 1833(m) of the Social Security Act specifically provides for a 10 percent bonus payment to physicians, including psychiatrists, located in areas that are designated (under section 332[(a][1][A] of the Public Health Services Act) as HPSAs. This section of the Public Health Services Act refers to geographic HPSAs for primary care as well as mental health services.

Consequently, psychiatrists located and serving in a mental health HPSA are eligible to receive bonus payments.

Like you, my concern is that residents living in HPSAs receive the best health care possible. And while 10 percent may not seem like much, it will help make these areas more attractive to qualified health care professionals—which is why my office responded so vigilantly when the aforementioned clinician, located in Fayette County, Pa., was told that mental health services were not included.

The person contacted my district office in May after receiving a letter from a contractor requesting a refund of overpayment. The contractor asserted that the clinician incorrectly reported services rendered in an HPSA area.

Fayette County became a mental health HPSA on October 20, 2000, due to unusually high needs for mental health services, as indicated by an elderly ratio of .33 and a poverty rate of 21.9 percent. Fayette County also meets the other necessary criteria to be classified as a mental health HPSA:

• A population-to-psychiatrist ratio greater than or equal to 15,000 to 1. Fayette County’s ratio is 144,501 to 1.

• A population-to-core-mental-health professional ratio greater than or equal to 4,500 to 1. Fayette County’s ratio is 23,689 to 1.

My office petitioned Certified Medicare Services (CMS), which said, in no uncertain terms, that mental health professionals are included. Thus, since October 20, 2000, health professionals practicing in Fayette County—including psychiatrists—have been eligible for bonus payments.

My concern is that this is not an isolated incident—that many other psychiatrists rendering services in an HPSA, including many of you, have been overlooked or misinformed when it comes to bonus payments.

I urge any clinician who has been informed that psychiatrists are not eligible for a bonus, or who has been subjected to repayment, to contact the local CMS representative in your state. In the event you need some technical assistance, please contact your local member of Congress. If the need arises, please feel free to contact my office directly.

As a member of Congress, I have been very active in health care issues that affect all Americans. There are currently more than 3,000 designated mental health HPSAs in this country, nearly 100 in Pennsylvania alone. I hope this information will be of use as you continue to provide dedicated mental health services to thousands of Americans each and every day.

Frank Mascara is a Democrat representative from Pennsylvania’s 20th congressional district.

Rep. Mascara can be reached in Washington, D.C., at 314 Cannon House Office Building, Washington, D.C. 20515 or (202) 225-4665; in Pennsylvania: Professional Plaza, Suite 210, 625 Lincoln Avenue, North Charleroi, Pa. 15022 or (724) 483-9016. ▪