APA Office Tackles Reimbursement, Managed Care Concerns
OHSF is involved in advocating for psychiatrists who participate in Medicare through building and maintaining working relationships with staff at the Centers for Medicare and Medicaid Services (CMS) and with Medicare carrier and fiscal intermediary medical directors, as well as with the psychiatry Carrier Advisory Committee representatives in each state. These representatives comprise APA’s Medicare Advisory Committee (MAC).
In conjunction with the MAC and other APA components, staff is working on several issues that pertain to physician payments under Medicare Part B. A model medical review policy for psychiatry is being developed for APA approval and will be presented to CMS for adoption. We anticipate this will solve many of the problems our members have been encountering with Medicare reimbursement.
Also, staff is collaborating with the American Bar Association to ensure that Medicare carriers honor the Alzheimer’s exemption to the outpatient mental health services limitation in its payment policies. This issue is of special concern to psychiatrists who do medication management for dually eligible (Medicare and Medicaid) patients with dementia. Many psychiatrists are receiving only 50 percent of the Medicare-allowed fee to which they are entitled when they see these patients.
As for Medicare Part A, OHSF is working closely with APA’s Committee on Reimbursement for Psychiatric Care on the proposed Prospective Payment System (PPS), which will change the way hospital inpatient psychiatric care is reimbursed. Through an arrangement with the Greater New York Hospital Association, which provided the analytical work, the committee and OHSF staff developed a methodology for determining Part A payments. The proposed methodology to be put forward by CMS is believed to be largely based on this work.
As part of APA’s Business Initiative, OHSF and the Committee on APA/Business Relations are working with purchasers of health insurance in the private sector, which account for approximately 50 percent of all third-party reimbursement in the United States. At least for the foreseeable future, it is the business world that will largely control changes in the way health care is delivered and paid for, and APA must be in a position to have a seat at the table. To that end, OHSF has developed contacts with key players in major U.S. corporations involved in reform efforts, some of whom are also members of the American Psychiatric Foundation’s National Partnership for Workplace Mental Health. As part of this outreach, OHSF publishes a quarterly newsletter, Mental HealthWorks, whose goal is establishing a dialogue between psychiatry and the business community. Each issue of Mental HealthWorks is sent to 12,000 APA members and 13,000 corporate executives. If you are not already receiving this publication, refer to the contact information at the end of this article for OHSF.
Today Medicaid is the dominant source of public-sector funding for mental health services. In response to the dwindling dollars allocated for mental health services, OHSF spearheaded the formation of an alliance with representatives from the National Alliance for the Mentally Ill and the National Mental Health Association. This alliance is working to ensure that Medicaid patients who suffer from mental illnesses will continue to have access to the psychiatric care and psychotropic medications they require, despite the downturn in the economy. OHSF staff, with the support of APA’s Committee on Public Funding for Psychiatric Services, has been involved with the district branches on this issue as well, attending Medicaid Pharmacy and Therapeutics Committee hearings and testifying before state legislatures on the nature of psychotropic medications and the necessity for maintaining patient access to the most appropriate care.
Working with the Committee on RBRVS, Codes, and Reimbursement, OHSF staff serve as APA’s point of contact to the AMA’s reimbursement-related committees, which include the CPT Editorial Panel, RVS Update Committee, and Practice Expense Advisory Committee. Their goal is to ensure that psychiatry’s needs are represented when additions or changes are made to the CPT codes or to the values that form the basis of the Resource Based Relative Value Scale (RBRVS) system. This system serves as the basis for how medical services are valued and reimbursed by both public and private payers.
In conjunction with APA’s Committee on Managed Care, OHSF has developed working relationships with the major managed behavioral health care organizations (MBHOs) and third-party payers. This has enabled APA to have a role when changes are made and has allowed staff to support APA members as they navigate the murky waters of their relationships with MBHOs.
In addition to its advocacy work, OHSF provides APA members with hands-on support through its Managed Care Help Line, which receives approximately 140 calls monthly. Members receive help for problems they are having with managed care companies, Medicare, and CPT coding. Besides having a number of resource documents available to respond to members’ general questions, OHSF staff try to resolve problems members are having with payers. The relationships developed through OHSF’s advocacy work often allow staff to find solutions to problems that individual members thought had been hopeless.
Individualized CPT coding assistance is available to APA members through the CPT Coding Network, which provides access to APA’s coding experts from the Committee on RBRVS, Codes, and Reimbursement. Coding queries are e-mailed or faxed to the experts for their advice and response.
For years OHSF published the newsletter Psychiatric Practice and Managed Care (PPMC), which delivered timely information on practice management. PPMC continues to serve APA members as a regular feature in Psychiatric News.
Also, the collective expertise of the office is highlighted in the handbook Practice Management for Early Career Psychiatrists, first published in 1999 and updated annually. This book provides “how-to” information for establishing and maintaining a practice and has proved to be extremely popular with psychiatry residents and early career psychiatrists, as well as veteran APA members. It is now posted on APA’s Web site in the Members Corner area at www.psych.org/members/ecp/bk/ecpbook02.pdf.
One of APA’s most prestigious and long-standing award programs, the Psychiatric Services Achievement Awards, is housed within OHSF. The goal of this annual awards program is to recognize and publicize innovative programs that can serve as models of creative service delivery in community and public psychiatry. Each of the two winning programs receives a $10,000 grant from Pfizer and national publicity.
OHSF has an annual budget of $768,514 and is staffed by 6.5 FTEs. You may contact the office by phone through its Managed Care Help Line at (800) 343-4671 or by e-mail at [email protected].
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