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New Member Benefit: Office Manager Listserv

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Friday, September 28, 2018

Part of my job, as Director of Professional Affairs for our association, is to communicate with as many of you as possible about everyday practice challenges you face, particularly those involving interacting with insurance companies. I am always looking for better or more innovative ways of tackling the problems we face in this area. 

During my time providing help and support around insurance issues, I have noted that I often end up working directly with many practice office managers. Recently, one of our insurance committee leaders, Dr. Leslie McClure, suggested that OPA find a way to help office managers interact directly with each other, or with me. From this concept, a new FREE member benefit was born: OPA should have a separate listserv specifically for office managers. With the help of OPA Director of Membership Carolyn Green, we now have that listserv available. 

Our vision for this listserv is that it will be a tool for those who do regular insurance billing, whether they are small practice psychologist, office manager, or office billing specialist. The topics of discussion will be questions or suggestions pertaining to billing practices, CPT codes, diagnostic codes, pre-authorizations, etc. I and other insurance committee members will monitor the listserv closely to serve as a resource for users. 

Each OPA member may designate ONE individual or email address to be part of the group. If you feel you or your office personnel would benefit from joining this list, I encourage you to sign-up using our online form.

Should you have any questions about this new listserv, please contact OPA at 614-224-0034 ext. 11, or email me.

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Claim Rejections from United Health Care Community Plan

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Thursday, August 30, 2018

Recently I've read posts on the listserv or received individual emails regarding claim rejections from United Health Care Community Plan, which is a Medicaid Managed Care plan.  The rejections are for basic services including psychotherapy.  There has been ongoing speculation about whether this may be a new plan which does not include behavioral health services.  EOB's received by providers even include a rejection reason which states psychotherapy is not a covered service.   To clarify, this plan is required to cover these basic services.  When managed care companies contract with the State of Ohio to manage a Medicaid program, they are required according to their agreement to offer all services offered directly by Medicaid.

In recent weeks, I have been in ongoing communication with UHCCP regarding these claim rejections which they acknowledge were done in error.  According to the information I received during a conference call this morning, the rejections were the result of a systems error associated with large systems changes they were required to make, and as of today they believe the problem has been solved.   Their hope is that all claims for initial evaluation and psychotherapy will be processed appropriately from this date forward (test claims have been successful), and that wrongly rejected claims will be reprocessed and reimbursed soon.   Panel members will be receiving a notice directly from UHCCP soon regarding this issue.

I urge OPA members to email me if your experiences with UHCCP are not consistent with this.  I also urge anyone to reach out regarding any claim rejection from any company that seems questionable. 

 

 

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Working with Medicare: What Are My Options?

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Monday, July 30, 2018

Recently an OPA member asked me about regulations associated with providing psychological services to clients covered by Medicare. In helping this psychologist sort through the complex options and legal requirements, it became clear to me that many of our members could benefit from extra support and information on this topic. Since anyone who is a licensed psychologist in Ohio potentially can be a Medicare provider, they are affected by the laws that govern their interaction with Medicare clients.

Federal regulations state that a licensed psychologist may choose to either enroll as a Medicare providers or “opt out.” Enrolling as a Medicare provider means the psychologist agrees, among other things, to accept the Medicare-approved amount as full payment for covered services. “Opting out” means that the psychologist submits an affidavit to Medicare agreeing neither the psychologist nor their client covered by Medicare will submit the bill to Medicare for services rendered. Instead, the client will pay the psychologist out-of-pocket and neither party is reimbursed by Medicare. Once a psychologist has opted out, a private contract must be signed between the psychologist and the client covered by Medicare before psychological services can be provided. The contract must state a number of important points, including that neither can receive payment from Medicare for the services that were performed.  This contract must:

  • Be in writing and in print sufficiently large to ensure that the client is able to read the contract
  • Clearly state whether the psychologist is excluded from Medicare.
  • State that the client or his or her legal representative accepts full responsibility for payment for the physician’s or practitioner’s charge for all services furnished by the psychologist.
  • State that the client or his or her legal representative understands that Medicare limits do not apply to what the psychologist may charge for items or services furnished by the psychologist.
  • State that the client or his or her legal representative agrees not to submit a claim to Medicare or to ask the psychologist to submit a claim to Medicare.
  • State that the psychologist or his or her legal representative understands that Medicare payment will not be made for any items or services furnished by the psychologist that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
  • State that the client or his or her legal representative enters into the contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that the client is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out.
  • State the expected or known effective date and expected or known expiration date of the opt-out period.
  • State that the client or his or her legal representative understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
  • Be signed by the client or his or her legal representative and by the psychologist.

Once a psychologist has opted out, the opt out status lasts for two tears, and is renewed automatically at the end of the two-year period. The opt out status may not be terminated during that period unless the provider is opting out the very first time. In that case, the opt out may be terminated within the first 90 days of the period. These opt outs may be cancelled by notifying Medicare before 30 days prior to the beginning of the next two tear period. 

Medicare offers a handout available in PDF format summarizing these requirements, including an opt out affidavit form. It can be downloaded here: https://www.cgsmedicare.com/partb/enrollment/part_b_optout.pdf

Completed affidavit forms should be sent to:

CGS Administrators, LLC
J-15 Part B Provider Enrollment
PO Box 20017
Nashville, TN 37202

I can also be contacted directly for a copy of this handout. 

My hope is that this summary answers most questions for our members on this topic. However, I understand questions about specific situations may arise.  Please feel free to reach out to me directly (jbroyles@ohpsych.org) if you need more individualized support.

Jim Broyles, PhD
Director of Professional Affairs
Ohio Psychological Association

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Screening: An Overlooked Billing Opportunity

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Tuesday, May 22, 2018

At the end of April, I attended OPA’s convention, held annually each spring in the Central Ohio area.  Each time I attend, I am reminded of one of the greatest benefits of the event: opportunities for networking.  The experience of networking offers many benefits to psychologists, such as the chance to identify resources, get new ideas for our professional work, share our expertise, or just connect a face to a name.  Few other features of our association give these advantages. 

For example, at one point I was part of a discussion involving psychological services and billing codes.  As is often the case, the conversation began to focus on which services were reimbursed by insurance companies (a topic of discussions I am frequently involved in).  One of my colleagues reminded me that a separate billing for use of screening instruments was allowed by most insurance companies.  I realized that many psychologist, especially folks in private practice, were unaware of or taking advantage of this.  My next idea was that I need to make sure I am passing this information on to OPA members.

My hope is that more psychologists are becoming aware of the importance of measuring and documenting the effectiveness of their work through outcome measures, particularly those who are practicing psychotherapists.  The use of screening instruments can help accomplish this task.  Screening instruments such as Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7), Alcohol Use Disorders Identification Test (AUDIT-C), are commonly used to detect the presence of symptoms and can be used pre, during, and post intervention.  While insurance companies vary on how frequently the use of these measures can be reimbursed, most provide some reimbursement for screening procedures when billed along with initial assessment or psychotherapy codes.  

As a result of requirements created by the Affordable Care Act, CPT Code 96127 was created in 2015.  Defined as brief emotional/behavioral assessment, with scoring and documentation, per standardized instrument, this code may be billed along with an initial assessment or psychotherapy code for each instrument administered.  Though in many cases the reimbursement rates are nominal, regular use of this procedure can create some added income for many practitioners.  Doing so also provides an incentive for clinicians to begin outcome measurement for their work.  For those of you who regularly use screening or brief assessment instruments, I encourage you to remember to bill CPT 96127 along with your regularly used code(s).  For those of you who do not make regular use of screening, I encourage you to start.  As always please reach out to me (jbroyles@ohpsych.org) with questions and comments.

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Retirement Checklist

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Thursday, April 12, 2018

Thinking of retirement?  You are not alone.  Questions about retirement are among those most commonly received by OPA staff.  Below is a checklist of important retirement considerations.  In assembling these guidelines, I have integrated more general ideas offered by APAPO with Ohio rules governing psychologists.  Some of the guidelines have links to other very helpful APAPO documents.  You may access these if you are a member.  (If you are not, I urge you to join!)

Clients and Their Records

  • Inform your current clients be sure to leave adequate time for termination or referral.
  • Talk to the psychologists to whom you will refer clients who need ongoing treatment — find out about their availability, insurance accepted, location, office hours and areas of expertise
  • Ensure continuity of care by providing referrals to clients who require ongoing services and helping them with the transition
  • Obtain informed consent and transfer a copy of your clients' records to the new providers
  • Inform your clients other health care professionals and keep them up-to-date on the status of closing your practice
  • Attempt to notify your past clients. There are a number of approaches you might take, including sending a letter and/or placing a notice in the local papers of the area you serve, on your website and in other community forums. Be sure to include information about how to contact you or access client records.
  • Be mindful of records you are required to maintain.  Ohio rule regarding this:

OAC 4732-17-01 (B) Negligence:
(7) Maintenance and retention of records.
(b) To meet the requirements of these rules, but not necessarily for other legal purposes, the license holder shall ensure that all contents in the professional record are maintained for a period of not less than seven years after the last date of service rendered, or not less than the length of time required by other regulations if that is longer. A license holder shall retain records documenting services rendered to minors for not less than two years after the minor has reached the age of majority or for seven years after the last date of service, whichever is longer.

  • Identify a person who will maintain current records you are required to keep and protect their confidentiality.  Make sure you have an updated written plan to facilitate the transfer of these records, and that the person who knows the location of this plan is identified by you to the Ohio Board of Psychology.  Ohio rule regarding this:

OAC 4732-17-01 (B) Negligence
(7) Maintenance and retention of records.
(c) A license holder shall store and dispose of written, electronic, and other records of clients in such a manner as to ensure their confidentiality. License holders shall prepare in advance and disseminate to an identifiable person a written plan to facilitate appropriate transfer and to protect the confidentiality of records in the event of the license holder's withdrawal from positions or practice. Each license holder shall report to the board on the biennial registration (renewal) form the name, address, and telephone number of a license holder or other appropriate person knowledgeable about the location of the written plan for transfer and custody of records and responsibility for records in the event of the licensee's absence, emergency or death. The written plan referenced in this rule shall be made available to the board upon request.

Finances

  • Talk to your attorney and accountant to determine whether selling your practice is a viable and worthwhile option. Also, be aware of ethical issues related to selling your practice, and seek appropriate consultation as necessary

  • If selling your practice, decide whether to work with a broker to help you navigate this potentially complicated process that requires a sophisticated understanding of local and state laws, business valuation, marketing strategy, tax implications and contracts

  • Collect any accounts receivable

  • Pay off any outstanding debts
  • Work with your accountant to organize your financials records (e.g., financial reports, tax documentation, contracts)

  • Talk to your accountant and/or tax professional about the tax implications of closing or selling your practice and strategies to reduce your tax liabilities

  • Once all of your finances have been reconciled, close bank accounts associated with your practice

Business Issues

  • Discuss the arrangements with your partners — if selling or transferring your ownership to your partner(s), be sure to work closely with your attorney to protect all parties involved

  • Inform your office staff far in advance

    Notify all your referral sources

    Inform other professional contacts and relevant entities, including the psychology board, professional organizations, insurance panels and other parties with which you contract, your billing and answering services and other practice consultants 

  • If you rent office space, give notice to terminate your lease in the manner and time frame that your leasing contract requires. If you own, take steps to sell or rent your office

  • Sell, donate or dispose of office equipment, such as photocopiers, fax machines, and furniture. Remember that if any of this equipment contains confidential information, that information must be deleted in line with HIPAA requirements.

  • Use up any remaining office inventory

  • Contact the issuers of any business licenses and permits you hold

  • Cancel any utilities (e.g., electric, gas, water, phone, Internet) you pay for your office

  • Submit a change of address form with the post office. Depending upon your privacy concerns and where you want your professional mail delivered, you may want to consider obtaining a post office box for a period of time to make sure you do not miss any important correspondence

  • Cancel or forward any publications or subscriptions you received at your office

  • Forward your office telephone number or keep you answering service for a period of time. Place an outgoing message informing callers of your closure and giving instructions for contacting you or accessing their records

  • Call your professional liability insurance carrier — make sure you are covered for complaints filed after you close your practice. If your current policy does not cover this type of complaint, find out about purchasing a "tail" to your policy 

I hope you find this helpful.  For those of you who are more experienced with this process, please feel free to contact me with more tips others might find helpful.


Jim Broyles, PhD, OPA Director of Professional Affairs

This information is also available in a pdf version in the Professional Resources section of our website located under the Member Services tab. 
Note... This is a members' only restricted area. You will need to login to gain access to the Professional Resources page.

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Medicaid Behavioral Health Redesign: Rejected Claims

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Tuesday, February 27, 2018

As many of you are aware, the Medicaid Behavioral Health Redesign was implemented in Ohio at the beginning of the year.  A few of the insurance companies are reporting systems issues that need to be worked out.  United Health Community Plan reports many claims are being rejected with the code A-17—NPI not Billed.  UHCCP requests that everyone be aware of the following:

Behavioral Health Redesign is now in effect as of 1/1/2018 and Optum has identified a growing trend of inappropriate billing according to the Ohio Department of Medicaid’s coding specifications. A significant number of claims are being submitted and denied “A17 | NPI not Billed” because the NPI is not being reported on each detail line. Behavioral Health Redesign coding specifications indicate this is a requirement. 

For specific reference to this requirement, providers should visit: http://bh.medicaid.ohio.gov 
Provider > Manuals, Rates & Resources > IT Resources (Final) > EDI/IT Q&A Document

UHCCP reports that providers are not able to submit claims with rendering NPI at the line level through the UHC claims portal. This portal does not have the capacity to submit claims in this format.  Claims in this format will have to be sent paper claim or through a clearinghouse.

If you bill United Health Care Community Plan and you have questions about this, please feel free to email me.

Jim Broyles, Ph.D.,  OPA Director of Professional Affairs

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Prior Authorization Law Now In Effect

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Thursday, January 11, 2018

As many of you may remember, the “Prior Authorization Law,” which was passed in 2016, will begin its impact this year. The Ohio Psychological Association’s Advocacy Team worked very hard to contribute to the passage of this law (it was a featured priority for past OPA Legislative Days), and we should now see the benefits of its requirements.

Among other things, the law states:

For health insurance policies issued on or after January 1, 2018, the insurance company must: 

  • Make preauthorization forms available electronically
  • Allow preauthorization forms to be submitted electronically
  • Respond to requests for authorization within
    • 48 hours for urgent situations
    • 10 days for nonurgent situations
  • List preauthorization requirements on the company’s website 
  • Provide a streamlined appeal process including reasonable timelines for denied authorizations
  • Prohibit retroactive denial of authorizations granted

In the past, I have provided support for a number of psychologists who were requesting help with obtaining preauthorization for testing or for an extended therapy session time. This law would affect the processes involved here, requiring them to be clear and accountable. 

Please feel free to give me feedback about what you are encountering as you interact with insurance companies. Are you finding these features available from insurance companies on their websites?  Are you aware of law violations?  

I welcome your questions as well as your feedback.

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Anthem Offers CPT 90837 Documentation Guidelines

Posted By Karen J. Hardin, Tuesday, November 7, 2017
Updated: Tuesday, November 7, 2017

Several OPA members who are also panel providers for Anthem Blue Cross Blue Shield have reached out to me regarding letters they have recently received. The letter is similar to communications received from other insurance companies in the past, addressing the providers use of CPT Code 90837. Psychologists who receive the letter are informed that their use of CPT Code 90837 (60-minute psychotherapy session) is “higher than the expected billing distribution as determined by the average billing behavior of other physicians within your specialty and peer group.” The letter goes on to state, “Our goal is to help providers ensure that the documentation and reporting guidelines are followed and that their documentation supports the level of care billed for each service.”

Letter recipients have reached out to me expressing concern and confusion regarding the purpose of the letter.  Most feel confused about the meaning of the above statements. In an effort to help, I reached out to Anthem and asked for more information. In their response, Anthem clarified: “our letter is strictly educational in nature and its purpose is to ensure that your documentation supports the codes that are being billed.” Their response continues by outlining the documentation they would expect to see to support the CPT 90837 service billed:

  • Date of service
  • Length of session (start/end time), therapy time with patient and/or family
  • Therapeutic maneuvers utilized
  • Diagnosis -for each visit- related to treatment and therapy for the visit 
  • Progress or lack of progress to the goals
  • Updates to treatment plan if necessary
  • Provide signature (Electronic or written)

Also to note, these services are NOT included in the “time” for the session:

  • Time spent arranging services/appointments
  • Time spent in communication with other healthcare providers
  • Time spent documenting or providing reports

The intent of the letter, then, is to remind recipients to follow documentation guidelines for CPT Code 90837. No information was given on whether record audits should be expected at some point in the future. However, it seems clear that following these guidelines should help Anthem providers pass audits with no issue. I would also like to note that these record keeping guidelines are very similar to current standard accepted practices for the insurance industry and to recommendations I have given in the past.  

I hope you find this helpful.  Please feel free to stay in touch should you have other issues or concerns.

Jim Broyles, PhD
OPA Director of Professional Affairs

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Adjustments of Previously Paid Claims

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Thursday, October 12, 2017

I was recently contact by an OPA member who was encountering a difficult situation with an insurance company.  He received notice from the company in question stating a prior reimbursement they made was invalid, and they were therefore asking for the payment to be returned.  The initial payment had been made more than two years prior to the date the determination notice had been sent.  The psychologist contacted me about the legitimacy of this determination and request.  Like so many of us, he vaguely recalled there are limits to such “take back” requests, but he was unsure of the specifics.  (Apparently the insurance company making this determination was somewhat lacking in understanding, also). 

I reminded him of Ohio law on this topic, which I am copying below.  Insurance companies may look back and make a new determination about previously paid claims, but they are limited to a two-year period.  In other words, a request for return of paid claims is limited to the two-year period immediately preceding the notice requesting the return of funds.  The following is taken from the Ohio Department of Insurance website:

Adjustments of Previously Paid Claims

Claim payments that are made on or after July 24, 2002, are deemed final two years after the payment is made. After that date, the amount of the payment is not subject to adjustment, except in the case of fraud by the provider. 
 
A third-party payer may recover the amount of any part of a payment that the third-party payer determines to be an over-payment if the recovery process is initiated not later than two years after the payment was made to the provider. 
Upon determination of an over-payment a third-party payer shall send a notice to the provider that contains the following:

  1. The full name of the beneficiary who received the health care services for which over-payment was made;
  2. The date or dates the services were provided;
  3. The amount of the over-payment;
  4. The claim number or other pertinent numbers;
  5. A detailed explanation of basis for the third-party payer's determination of over-payment;
  6. The method in which payment was made, including, for tracking purposes, the date of payment and, if applicable, the check number;
  7. That the provider may appeal the third-party payer's determination of over-payment, if the provider responds to the notice within thirty (30) days;
  8. The method by which recovery of the over-payment would be made, if recovery proceeds under division (B) of this section.

Please note number seven above which allows for an appeal of the re-determination.  I urged the psychologist who reached out to me to appeal the adjustment determination, including a copy of the above information.

I hope you find this reminder helpful.  Please feel free to let me know whether you have encountered similar difficulties and about any problems you had responding to such requests.  

Jim Broyles, PhD
OPA Director of Professional Affairs

 

 

 

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Insurance Core Issues: Ohio's Prompt Payment Law

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Wednesday, August 23, 2017

I have received a number of questions and requests in the past two months regarding difficult insurance issues encountered by OPA members.  The problems involved range from delayed reimbursement to challenges with prior authorizations. Since many of these difficulties stem from a few basic core issues, I thought it might be helpful, now and in the next few weeks, to remind everyone of a few important consumer and provider protection laws which give needed support for nearly every practicing psychologist who must interact with health insurance companies.  

The first of these is Ohio’s Prompt Payment Law, which establishes strict time frames for the processing and payment of claims by insurance companies.  Specifically, the law states:

  1. A third-party payer has fifteen (15) days from receipt to notify a provider when a materially deficient claim is received. Examples of materially deficient claims include claims with an incorrect patient name or benefit contracts number, a patient that cannot be identified, a claim without as or treatment code or a claim without a provider's identifying number. The fifteen (15) day time period and the time spent correcting the deficiencies do not count toward the calculation of time in which a claim must be processed.
  2. A third-party payer has thirty (30) days to process a claim if no supporting documentation is needed.
  3. A third-party payer has forty-five (45) days to process a claim if the third-party payer requests additional supporting documentation. However, third-party payers must request supporting documentation within thirty (30) days of the initial receipt of the claim. The time period of forty-five (45) days is suspended until the third-party payer receives the last piece of information requested in the initial thirty (30) day period.
    • The time period is not suspended if a third-party payer requests additional supporting documentation after receiving initially requested information.
    • A request for additional supporting documentation that is made outside the thirty (30) day time period and that is based on information received in the initial request regarding a previously unknown pre-existing condition may suspend the forty-five (45) day processing time.
  4. A third-party payer may refuse to process a claim submitted by a provider if the provider submits the claim later than forty-five (45) days after receiving notice from a different third-party payer or a state or federal program that that payer or program is not responsible for the cost of the health care services, or if the provider does not submit the notice of denial from the different third-party payer or program with the claim.
  5. A third-party payer that has a timely filing requirement must process an untimely claim if all the following apply:
    • The claim was initially submitted to a different third-party payer or state or federal program;
    • The provider submits the claim to the second payer within forty-five (45) days of receiving notice that the first payer denied the claim; and
    • The provider submits the notice of denial along with the claim
  6. When a claim is submitted later than one year after the last date of service for which reimbursement is sought, a third-party payer shall pay or deny the claim not later than ninety (90) days after receipt of the claim or, alternatively, pursuant to the requirements of sections 3901.381 to 3901.388 of the Revised Code.

Many reimbursement issues encountered by psychologists may be eligible for a complaint under this law.  For example, an insurance company may review a claim to determine whether it was medically necessary.  However, they may not withhold payment, beyond the time frames stipulated, while making this determination.  The timelines above still apply.  

If you need to file a Prompt Pay Law complaint or any other complaint with the Ohio Department of Insurance (ODI), the best way is to establish an ODI Provider Gateway Account.  Once established, filing complaints with ODI becomes streamlined.  Instructions for establishing this account with ODI may be found here:
https://legacy.insurance.ohio.gov/ODILogon/Legacy/content/Documents/PC/ProviderGatewayAccount.pdf

I encourage all psychologists who interact with insurance companies to establish this account with ODI.  Providers may also use a printed form:
http://www.insurance.ohio.gov/forms/documents/INS0505.pdf

It may be helpful to share this information with office managers.  They may contact me directly for questions and support, providing they work for an OPA member.  In the next few weeks, I will be providing information on more laws associated with these core issues of difficulty affecting many of us.  In many cases, the solution may involve interacting with ODI, so following the above suggestion will facilitate my recommendations in the future. (Please note: ODI does not govern Medicaid or Medicare plans.  Please contact me directly for help with these).

Please let me know if you have comments or questions.

Jim Broyles, PhD
OPA Director of Professional Affairs

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