1. DPH 2004 Maintaining and Expanding Reimbursement Opportunities in Mental Health: Medicare as a Benchmark

2. DPH 2004 Women & Children’s Health Network Division of Public Health Chapel Hill, North Carolina May 12, 2004 Antonio E. Puente, Ph.D. Department of Psychology University of North Carolina at Wilmington Wilmington, NC 28403

3. DPH 2004 Contact Information Websites Websites –Univ = www.uncw.edu/people/puente www.uncw.edu/people/puente –Practice = www.clinicalneuropsychology.us E-mail E-mail –University = Puente@uncw.edu Puente@uncw.edu –Practice = Puente@clinicalneuropsychology.us Telephone Telephone –University = 910.962.3812 –Practice = 910.509.9371

4. DPH 2004Acknowledgments  Department of Psychology, UNC-Wilmington  NCPA Board of Directors, Practice Division, & Staff  NAN Board of Directors, Executive Directors’ Office, Policy and Planning Committee, & Professional Affairs and Information Office  Division 40 Board of Directors & Practice Committee  Practice Directorate of the American Psychological Association  American Medical Association’s CPT Staff  CMS Medical Policy Staff  Selected Individuals (e.g., Jim Georgoulakis)

5. DPH 2004 Background (1988 – present)  North Carolina Psychological Association (e)  APA’s Policy & Planning Board; Div. 40 (e)  American Medical Association’s Current Procedural Terminology Committee (IV/V) (a)  Health Care Finance Administration’s Working Group for Mental Health Policy (a)  Center for Medicare/Medicaid Services’ Medicare Coverage Advisory Committee (fa)  Consultant with the North Carolina Medicaid Office;North Carolina Blue Cross/Blue Shield (a)  NAN’s Professional Affairs & Information Office (a) (legend; a = appointment, fa = federal appointment, e = elected)

6. DPH 2004 Purpose of Presentation Increase Reimbursement Increase Reimbursement Increase Range, Type & Quality of Services Increase Range, Type & Quality of Services Decrease Fraud & Abuse Decrease Fraud & Abuse Provide Guidelines for Professional Services Provide Guidelines for Professional Services Maintain Professional Stature Within Psychology Maintain Professional Stature Within Psychology Increase Professional Stature in Health Care, in general Increase Professional Stature in Health Care, in general

7. DPH 2004 Outline of Presentation Medicare Medicare Current Procedural Terminology: Basic Current Procedural Terminology: Basic Current Procedural Terminology: Related Current Procedural Terminology: Related Relative Value Units Relative Value Units Current Problems & Possible Solutions Current Problems & Possible Solutions Future Directions & Problems Future Directions & Problems Resources Resources

8. DPH 2004 Outline: Highlights New Codes New Codes Expanding Paradigms Expanding Paradigms Fraud, Abuse; Coding & Documentation Fraud, Abuse; Coding & Documentation The Problem with Testing The Problem with Testing

9. DPH 2004 Medicare: Overview Why Focus on Medicare Why Focus on Medicare The Medicare Program The Medicare Program Local Medical Review (policy & panels) Local Medical Review (policy & panels)

10. DPH 2004 Medicare: Why The Standard The Standard –Coding –Value –Documentation Approximately 50% for Institutions Approximately 50% for Institutions Approximately 33% for Outpatient Offices Approximately 33% for Outpatient Offices Becoming the Standard for Workers Comp. Becoming the Standard for Workers Comp. Increasing Percentage for Forensic Work Increasing Percentage for Forensic Work

11. DPH 2004 Medicare: Overview New Name: HCFA now CMS New Name: HCFA now CMS –Centers for Medicare and Medicaid Services New Charge: Simplify New Charge: Simplify New Organization: Beneficiary, Medicare, Medicaid New Organization: Beneficiary, Medicare, Medicaid Benefits Benefits –Part A (Hospital) –Part B (Supplementary) –Part C (Medicare+ Choice)

12. DPH 2004 Medicare: Local Review Local Medical Review Policy Local Medical Review Policy –LMRP vs National Policy –Location of LMRPs Carrier Medical Director Carrier Medical Director –A Physician-based Model Policy Panels Policy Panels –Lack of Understanding of Their Roles –Lack of Representation on Such Panels

13. DPH 2004 Medicare Payment (since 1993) Surgical Surgical –Higher Reimbursement than Cognitive Cognitive Cognitive –Physician Cognitive Work –Supporting Equipment & Staff

14. DPH 2004 Current Procedural Terminology: Overview Background Background Codes & Coding Codes & Coding Existing Codes Existing Codes Model System X Type of Problem Model System X Type of Problem Medical Necessity Medical Necessity Documenting Documenting Time Time

15. DPH 2004 CPT: Background American Medical Association American Medical Association –Developed by Surgeons (& Physicians) in 1966 for Billing Purposes –7,500+ Discrete Codes CMS CMS –AMA Under License with CMS –CMS Now Provides Active Input into CPT

16. DPH 2004 CPT: Background/Direction Current System = CPT 5 Current System = CPT 5 Categories Categories –I= Standard Coding for Professional Services –II = Performance Measurement –III = Emerging Technology

17. DPH 2004 CPT: Applicable Codes Total Possible Codes = Approximately 7,500 Total Possible Codes = Approximately 7,500 Possible Codes for Psychology = Approximately 40 to 60 Possible Codes for Psychology = Approximately 40 to 60 Sections = Five Separate Sections Sections = Five Separate Sections –Psychiatry –Biofeedback –Central Nervous Assessment –Physical Medicine & Rehabilitation –Health & Behavior Assessment & Management –Possibly, Evaluation & Management

18. DPH 2004 CPT: Development of a Code Initial Initial –Health Care Advisory Committee (non-MDs) Primary Primary –CPT Work Group –CPT Panel Time Frame Time Frame –3-5 years

19. DPH 2004 CPT: Psychiatry Sections Sections –Interview vs. Intervention –Office vs. Inpatient –Regular vs. Evaluation & Management –Other Types of Interventions Types of Interventions –Insight, Behavior Modifying, and/or Supportive vs. Interactive

20. DPH 2004 CPT: Psychiatry (cont.) Time Value Time Value –30, 60, or 90 Interview Interview –90801 Intervention Intervention –90804 - 90857

21. DPH 2004 CPT: Biofeedback Psychophysiological Training Psychophysiological Training –90901 Biofeedback Biofeedback –90875

22. DPH 2004 CPT: CNS Assessment Interview Interview –96115 Testing Testing –Psychological = 96100; 96110/11 –Neuropsychological = 96117 –Other = 96105, 96110/111

23. DPH 2004 CPT: Physical Medicine & Rehabilitation 97770 now 97532 97770 now 97532 Note: 15 minute increments Note: 15 minute increments

24. DPH 2004 CPT: Health & Behavior Assessment & Management Purpose: Medical Diagnosis Purpose: Medical Diagnosis Time: 15 Minute Increments Time: 15 Minute Increments Assessment Assessment Intervention Intervention

25. DPH 2004 CPT: Modifiers Acceptability Acceptability –Medicare = about 100% –Others = approximating 90% Modifiers Modifiers –22 = unusual or more extensive service –51 = multiple procedures –52 = reduced service –53 = discontinued service

26. DPH 2004 CPT: Model System Psychiatric Psychiatric Neurological Neurological Non-Neurological Medical Non-Neurological Medical Possibly, Evaluation & Management Possibly, Evaluation & Management

27. DPH 2004 CPT: Psychiatric Model (Children & Adult) Interview Interview –90801 Testing Testing –96100, or –96110/11 Intervention Intervention –e.g., 90806 –The challenge of New Mexico

28. DPH 2004 CPT: Neurological Model (Children & Adult) Interview Interview –96115 Testing Testing –96117 Intervention Intervention –97532

29. DPH 2004 CPT: Non-Neurological Medical Model (Children & Adult) Interview & Assessment Interview & Assessment –96150 (initial) –96151 (re-evaluation) Intervention Intervention –96152 (individual) –96153 (group) –96154 (family with patient) –96155 (family without patient)

30. DPH 2004 CPT: New Paradigms Initial Psychiatric Initial Psychiatric Next Neurological Next Neurological Now Medical Now Medical Medical as Evaluation & Management Medical as Evaluation & Management

31. DPH 2004 CPT: Evaluation & Management Role of Evaluation & Management Codes Role of Evaluation & Management Codes –Procedures –Case Management Limitations Imposed by AMA’s House of Delegates for CMS but not for Private Payers Limitations Imposed by AMA’s House of Delegates for CMS but not for Private Payers Health & Behavior Codes as an Alternative to E & M Codes Health & Behavior Codes as an Alternative to E & M Codes The Use of E & M Codes is Accepted by Some Third Party Reimburses (e.g., MedCost) The Use of E & M Codes is Accepted by Some Third Party Reimburses (e.g., MedCost) –Example; 99201 New Patient

32. DPH 2004 CPT: Diagnosing Psychiatric Psychiatric –DSM The problem with DSM and neuropsych testing of developmentally-related neurological problems The problem with DSM and neuropsych testing of developmentally-related neurological problems Neurological & Non-Neurological Medical Neurological & Non-Neurological Medical –ICD (or see NAN Paio web page; membership directory) –Neurological Code Updates Available by 01.01.03

33. DPH 2004 CPT: Medical Necessity Scientific & Clinical Necessity Scientific & Clinical Necessity Local Medical Review or Carrier Definitions of Necessity Local Medical Review or Carrier Definitions of Necessity Necessity = CPT x DX Necessity = CPT x DX Necessity Dictates Type and Level of Service Necessity Dictates Type and Level of Service Necessity Can Only be Proven with Documentation Necessity Can Only be Proven with Documentation

34. DPH 2004 CPT: Coding Matrices EMSCO & Fraud EMSCO & Fraud Underlying Problem = Medical Decision Making Underlying Problem = Medical Decision Making Do not use: Do not use: –Coding Matrices –Grids –Related Shortcuts

35. DPH 2004 CPT: Documenting Purpose Purpose Payer Requirements Payer Requirements General Principles General Principles History History Examination Examination Decision Making Decision Making

36. DPH 2004 Documentation: Purpose Medical Necessity Medical Necessity Evaluate and Plan for Treatment Evaluate and Plan for Treatment Communication and Continuity of Care Communication and Continuity of Care Claims Review and Payment Claims Review and Payment Research and Education Research and Education

37. DPH 2004 Documentation: Payer Requirements Site of Service Site of Service Medical Necessity for Service Provided Medical Necessity for Service Provided Appropriate Reporting of Activity Appropriate Reporting of Activity

38. DPH 2004 Documentation: General Principles Rationale for Service Rationale for Service Complete and Legible Complete and Legible Reason/Rationale for Service Reason/Rationale for Service Assessment, Progress, Impression, or Diagnosis Assessment, Progress, Impression, or Diagnosis Plan for Care Plan for Care Date and Identity of Observe Date and Identity of Observe Timely Timely Confidential Confidential

39. DPH 2004 Documentation: Basic Information Across All Codes Date Date Time, if applicable Time, if applicable Identify of Observer (technician ?) Identify of Observer (technician ?) Reason for Service Reason for Service Status Status Procedure Procedure Results/Finding Results/Finding Impression/Diagnoses Impression/Diagnoses Disposition Disposition Stand Alone Stand Alone

40. DPH 2004 Documentation: Chief Complaint Concise Statement Describing the Symptom, Problem, Condition, & Diagnosis Concise Statement Describing the Symptom, Problem, Condition, & Diagnosis Foundation for Medical Necessity Foundation for Medical Necessity Must be Complete & Exhaustive Must be Complete & Exhaustive

41. DPH 2004 Documentation: Present Illness Symptoms Symptoms –Location, Quality, Severity, Duration, timing, Context, Modifying Factors Associated Signs Follow-up Follow-up –Changes in Condition –Compliance

42. DPH 2004 Documentation: History Past Past Family Family Social Social Medical/Psychological Medical/Psychological

43. DPH 2004 Documentation: Mental Status Language Language Thought Processes Thought Processes Insight Insight Judgment Judgment Reliability Reliability Reasoning Reasoning Perceptions Perceptions Suicidality Suicidality Violence Violence Mood & Affect Mood & Affect Orientation Orientation Memory Memory Attention Attention Intelligence Intelligence

44. DPH 2004 Documentation: Neurobehavioral Status Exam Attention Attention Memory Memory Visuo-spatial Visuo-spatial Language Language Planning Planning

45. DPH 2004 Documentation: Testing Names of Tests (including edition/version) Names of Tests (including edition/version) Interpretation of Tests (narrative; possibly quantitative) Interpretation of Tests (narrative; possibly quantitative) Disposition Disposition Time/Dates Time/Dates –In Hours (rounded to nearest hour) –Document on Day Service is Provided –Might be Best to Separate from Interview

46. DPH 2004 Documentation: Intervention Reason for Service Reason for Service Status Status Intervention Intervention Results Results Impression Impression Disposition Disposition Time Time

47. DPH 2004 Documentation: Suggestions Avoid Handwritten Notes Avoid Handwritten Notes Do Not Use Red Ink Do Not Use Red Ink Avoid Color Paper Avoid Color Paper Document On and After Every Encounter, Every Procedure, Every Patient Document On and After Every Encounter, Every Procedure, Every Patient Review Changes Whenever Applicable Review Changes Whenever Applicable Avoid Standard Phrases Avoid Standard Phrases

48. DPH 2004 Documentation: Ethical Issues How Much and To Whom Should Information be Divulged How Much and To Whom Should Information be Divulged Medical Necessity vs. Confidentiality Medical Necessity vs. Confidentiality HIPAA vs. Documentation HIPAA vs. Documentation

49. DPH 2004 Time Defining Defining –Professional (not patient) Time Including: pre, intra & post-clinical service activities pre, intra & post-clinical service activities Interview & Assessment Codes Interview & Assessment Codes –Generally use hourly increments –For new codes, use 15 minute increments Intervention Codes Intervention Codes –Use 15, 30, or 60 minute increments

50. DPH 2004 Time: Definition AMA Definition of Time AMA Definition of Time Physicians also spend time during work, before, or after the face-to-face time with the patient, performing such tasks as reviewing records & tests, arranging for services & communicating further with other professionals & the patient through written reports & telephone contact. Physicians also spend time during work, before, or after the face-to-face time with the patient, performing such tasks as reviewing records & tests, arranging for services & communicating further with other professionals & the patient through written reports & telephone contact.

51. DPH 2004 Time (continued) Communicating further with others Communicating further with others Follow-up with patient, family, and/or others Follow-up with patient, family, and/or others Arranging for ancillary and/or other services Arranging for ancillary and/or other services

52. DPH 2004 Time: Defined Further Evaluation Versus Therapy Time Evaluation Versus Therapy Time –Therapy is Essentially Face to Face –Testing is Essentially Professional Time Inpatient Versus Outpatient Inpatient Versus Outpatient - If Outpatient: face to face only for E & M - If Inpatient: time on floor for E & M

53. DPH 2004 Time: Testing Quantifying Time Quantifying Time –Round up or down to nearest increment –Testing = 15 or 60 (probably soon 30) Time Does Not Include Time Does Not Include –Patient completing tests, forms, etc. –Waiting time by patient –Typing of reports –Non-Professional (e.g., clerical) time –Literature searches, learning new techniques, etc.

54. DPH 2004 Time (continued) Preparing to See Patient Preparing to See Patient Reviewing of Records Reviewing of Records Interviewing Patient, Family, and Others Interviewing Patient, Family, and Others When Doing Assessments: When Doing Assessments: –Selection of tests –Scoring of tests –Reviewing results –Interpretation of results –Preparation and report writing

55. DPH 2004 Reimbursement History Cost Plus Cost Plus Prospective Payment System (PPS) Prospective Payment System (PPS) Diagnostic Related Groups (DRGs) Diagnostic Related Groups (DRGs) Customary, Prevailing & Reasonable (CPR) Customary, Prevailing & Reasonable (CPR) Resource Based Relative Value System (RBRVS) Resource Based Relative Value System (RBRVS)

56. DPH 2004 Relative Value Units: Overview Components Components Units Units Values Values Current Problems Current Problems

57. DPH 2004 RVU: Components Physician Work Resource Value Physician Work Resource Value Practice Expense Resource Value Practice Expense Resource Value Malpractice Malpractice Geographic Geographic Conversion Factor (approx. $34) Conversion Factor (approx. $34)

58. DPH 2004 RVU: Values Psychotherapy: Psychotherapy: –Prior Value =1.86 –New Value = 2.0+ (01.01.02) Psych/NP Testing: Psych/NP Testing: –Work value= 0 –Hsiao study recommendation = 2.2 –New Value = undetermined Health & Behavior Health & Behavior –.25 (per 15 minutes increments)

59. DPH 2004 RVU: Acceptance Medicare Medicare Blue Cross/Blue Shield 87% Blue Cross/Blue Shield 87% Managed Care 69% Managed Care 69% Medicaid 55% Medicaid 55% Other 44% Other 44% New Trends: New Trends: –RVUs as a Model for All Insurance Companies –RVUs as a Basis for Compensation Formulas

60. DPH 2004 CPT x RVU

61. DPH 2004 Current Problems Definition of Physician Definition of Physician Incident to Incident to Supervision Supervision Face-to-Face Face-to-Face Time Time RVUs RVUs Work Values Work Values Qualification of Technicians Qualification of Technicians Practice Expense & Testing Survey Practice Expense & Testing Survey Payment Payment Prospective Payment System Prospective Payment System Skilled Nursing Facilities Skilled Nursing Facilities Provider Based Facilities Provider Based Facilities Focus for Fraud & Abuse Focus for Fraud & Abuse

62. DPH 2004 Current Problems: Highlights Work Value for Testing Codes Work Value for Testing Codes Provision & Coding of Technical Services (e.g., who is qualified to provide them) Provision & Coding of Technical Services (e.g., who is qualified to provide them) Mental vs. Physical Health Mental vs. Physical Health

63. DPH 2004 Problem: Defining Physician Definition of a Physician Definition of a Physician –Social Security Practice Act of 1980 –Definition of a Physician –Need for Congressional Act –Likelihood of Congressional Act –The Value of Technical Services of a Psychologist is $.83/hour (second highest after physicist) –Consequence of the preceding; grouping with non-doctoral level allied health providers

64. DPH 2004 Problem: Incident to Rationale for Incident to Rationale for Incident to –Congress intended to provide coverage for services not typically covered elsewhere Definition of Physician Extender Definition of Physician Extender –How –Limitations Definition of In vs. Outpatient Definition of In vs. Outpatient –Geographic Vs Financial Why No Incident to (DRG) Why No Incident to (DRG) Solution Available for Some Training Programs Solution Available for Some Training Programs Probably no Future to Incident to Probably no Future to Incident to

65. DPH 2004 Problem: More Incident to When is “Incident to” Acceptable: When is “Incident to” Acceptable: –Testing –Cognitive Rehabilitation; Biofeedback –Psychotherapy Definition Definition –Commonly furnished service –Integral, though incidental to psychologist –Performed under the supervision –Either furnished without charge or as part of the psychologist’s charge

66. DPH 2004 Problem: Incident to & Site of Service Outpatient vs. Inpatient Outpatient vs. Inpatient –Geographical Location –Corporate Relationship –Billing Service –Chart Information & Location

67. DPH 2004 Problem: Incident to versus Independent Service When Does Incident to Become Independent Service When Does Incident to Become Independent Service –Appearance of No Supervision –Clinical Decisions are Made by Staff –Ratio of Physician to Staff Time Becomes Disproportionate –Distance Difficulties –Supervision Difficulties

68. DPH 2004 Problems: Recent Difficulties with Incident to Who Bills Incident to Who Bills Incident to –Treating Physician Bills not the Supervising Physician –Then, Who is the Responsible Party The Physician Must Treat the Patient First The Physician Must Treat the Patient First Physician Bonuses Must Tied to a Groups’ Overall Pool of Income (e.g., not referral or possibly individual productivity) Physician Bonuses Must Tied to a Groups’ Overall Pool of Income (e.g., not referral or possibly individual productivity)

69. DPH 2004 Problem:Supervision Supervision Supervision –1.General = overall direction –2.Direct = present in office suite –3.Personal = in actual room –4.Psychological = when supervised by a psychologist

70. DPH 2004 Problem: Face-to-Face Implications Implications Technical versus Professional Services Technical versus Professional Services Surgery is the Foundation for CPT (and most work is face-to-face) Surgery is the Foundation for CPT (and most work is face-to-face) Hard to Document & Trace Non-Face-to- Face Work Hard to Document & Trace Non-Face-to- Face Work

71. DPH 2004 Problem: Time Time Based Professional Activity Time Based Professional Activity Current =15, 30, 60, & 90 Current =15, 30, 60, & 90 Expected = 15 & 30 Expected = 15 & 30

72. DPH 2004 Problem: RVUs Bad News Bad News –2000 = 5.5% increase –2001 = 4.5% increase –2002 = 5.4% decrease –2003 = 4.4 to 5.7% decrease ($34.14) Really Bad News Really Bad News –Bush Administration not supportive of changing the conversion formula –Change Continued to Probably 2005 Depending on Such Factors as the Stock Market (e.g., 5000)

73. DPH 2004 Problem: Work Value Physician Activities (e.g., Psychotherapy) Result in Work Values Physician Activities (e.g., Psychotherapy) Result in Work Values Psychological Based Activities (i.e., Testing) Have no Work Values Psychological Based Activities (i.e., Testing) Have no Work Values RVUs are Heavily Based on Practice Expenses (which are being reduced) RVUs are Heavily Based on Practice Expenses (which are being reduced) Net Result = Maybe Up to a Half Lower Net Result = Maybe Up to a Half Lower

74. DPH 2004 Problem: An Artificial Practice Expense Five Year Reviews Five Year Reviews Prior Methodology Prior Methodology Current Methodology Current Methodology Current Value = approximately 1.5 of 1.75 is practice Current Value = approximately 1.5 of 1.75 is practice Deadline for New Practice Expense = 2002 Deadline for New Practice Expense = 2002 –Currently in Check Due to the Ongoing Survey Expected Value = closer to 50% of total value at best Expected Value = closer to 50% of total value at best

75. DPH 2004 Problem: Work Value of Testing First Round First Round Second Round Second Round Third Round Third Round Current Round Current Round

76. DPH 2004 Problem: Qualification of Technician What is the Minimum Level of Training Required for a Technician? What is the Minimum Level of Training Required for a Technician? –Bachelor’s vs. Masters –Intern vs. Postdoctoral

77. DPH 2004 Problem: Payment Origins of the Problem Origins of the Problem –Balanced Budget Act of 1997 –Employer’s Cost for Health Care in 2002 = $5,000 per employee What Should Your Code Be Payed at? What Should Your Code Be Payed at? –www.webstore.ama-assn.org- State Legislation State Legislation –www.insure.com/health/lawtool.cfm www.insure.com/health/lawtool.cfm

78. DPH 2004 Problem: Payment Problems Payment Reduction Software Programs Payment Reduction Software Programs –Claimcheck (McKesson product; Cigna, PacifiCare) –Patterns (McKesson product; United) Refilling Refilling –51% require refilling of original forms –But, up to 60% do not follow up Errors Errors –54% = plan administrator –17% = provider – 29% = member

79. DPH 2004 Problem: Payment Use of HMOs & Third Party Use of HMOs & Third Party –Shift in Practice Patterns by Psychiatry (14% increase) –Exclusion of MSW, etc. –Worst Hit Are Psychologists (2% decrease) Compensation Compensation –Gross Charges –Adjusted Charges –RVUs –Receivables

80. DPH 2004 Problem: PPS Application of PPS (inpatient rehab) Application of PPS (inpatient rehab) Traditional Reimbursement Traditional Reimbursement Current Unbundling Current Unbundling Potential Situation Potential Situation

81. DPH 2004 Problem: Skilled Nursing Facility Consolidated Billing Consolidated Billing Excluded Codes in Consolidated Billing Excluded Codes in Consolidated Billing –96115 (Neurobehavioral Status Exam) –90901 & 90911 (Biofeedback)

82. DPH 2004 Problem: Provider-Based Facilities Is Facility Located on Main Hospital Campus or Within 35 Miles of it Is Facility Located on Main Hospital Campus or Within 35 Miles of it Appropriate Reporting Relationship Exists Between Hospital and Clinical Staff Appropriate Reporting Relationship Exists Between Hospital and Clinical Staff Medicare Cost Report Includes Facility Medicare Cost Report Includes Facility Records are Fully Integrated Records are Fully Integrated Facility is Presented to the Public as Part of the Hospital Facility is Presented to the Public as Part of the Hospital

83. DPH 2004 Problem: Expenditures & Fraud Projections Projections –Current 14% 14% –By 2011; 17% ($2.8 trillion) 17% ($2.8 trillion) Examples Examples –Nadolni Billing Service (Memphis) $5 million in claims to CIGNA for psychological services $5 million in claims to CIGNA for psychological services $250,000 fine (& tax evasion); July 12th $250,000 fine (& tax evasion); July 12th

84. DPH 2004 Defining Fraud Fraud Fraud –Intentional –Pattern Error Error –Clerical –Dates

85. DPH 2004 Problem: Fraud & Abuse 26 Different Kinds of Fraud Types 26 Different Kinds of Fraud Types Mental Health Profiled Mental Health Profiled Estimates of Less Than 10% Recovered Estimates of Less Than 10% Recovered Psychotherapy Estimates/Day = 9.67 hours Psychotherapy Estimates/Day = 9.67 hours –Review Likely if Over 12 Hours Per Day Problems with Methodology; Problems with Methodology; –MS level and RN –Limited Sampling

86. DPH 2004 Problem: Fraud Office of Inspector General Primary Problems Primary Problems –Medical Necessity (approximately $5 billion) –Documentation Psychotherapy (oig.hhs/gov/reports/region5/50100068) Psychotherapy (oig.hhs/gov/reports/region5/50100068) –Individual –Group –# of Hours –Who Does the Therapy Psychological Testing Psychological Testing –# of Hours –Documentation

87. DPH 2004 Problem: Fraud & “The Orange Book” Contractor Operations Contractor Operations –Strengthen Regional Offices Oversight –Improve Evaluation of Fraud Unit –Prevent Duplicate Payments for Same Service Hospital Operations Hospital Operations –Identify Patterns of Aberrant Overpayment –Improve External Review of Psychiatric Hospitals Managed Care Managed Care –Retool Medicaid Programs for Managed Care Nursing Homes Nursing Homes –Improve Assessments of Mental Illness –Identify Patients with Mental Illness

88. DPH 2004 Problem: The “Orange Book” (continued) Physicians/Allied Health Professionals Physicians/Allied Health Professionals –Improve Oversight of Rural Health Clinics –Eliminate Inappropriate Payments for Mental Health Services –Yet, Improve Medicaid Mental Health Programs

89. DPH 2004 Problem: Fraud (cont.) Nursing Homes Nursing Homes –Identification –Overuse of Services Children Children Experience Experience –California; Texas –Corporation Audit –Company Audit –Personal Audit

90. DPH 2004 Problem: Fraud (cont.) Estimated Pattern of Fraud Analysis Estimated Pattern of Fraud Analysis –For-profit Medical Centers –For-profit Medical Clinics –Non-profit Medical Centers –Non-profit Medical Clinics –Nursing Homes –Group Practices –Individual Practices

91. DPH 2004 Problem: Mental vs. Physical Historical vs. Traditional vs. Recent Diagnostic Trends Historical vs. Traditional vs. Recent Diagnostic Trends Recent Insurance Interpretations of Dxs Recent Insurance Interpretations of Dxs Limitations of the DSM Limitations of the DSM The Endless Loop of Mental vs. Physical The Endless Loop of Mental vs. Physical NOTE: Important to realize that LMRP is almost always more restrictive than national guidelines NOTE: Important to realize that LMRP is almost always more restrictive than national guidelines

92. DPH 2004 Problem: HIPAA Health Insurance Portability and Accountability Act Health Insurance Portability and Accountability Act Ethics versus Practicality Ethics versus Practicality

93. DPH 2004 Possible Solutions: General Approaches Better Understanding & Application of CPT Better Understanding & Application of CPT More Involvement in Billing (especially in large, medical, multidisciplinary, and academic settings) More Involvement in Billing (especially in large, medical, multidisciplinary, and academic settings) Comprehensive Understanding of LMRP Comprehensive Understanding of LMRP More Representation/Involvement with AMA, CMS, More Representation/Involvement with AMA, CMS, & Local Medical Review Panels Meetings with CMS Meetings with CMS Survey for Testing Codes Survey for Testing Codes APA: Increased Staff & Relationship with CAPP APA: Increased Staff & Relationship with CAPP

94. DPH 2004 Possible Solutions: Resources General Web Sites General Web Sites –www.nanonline.org/paio –www.cms.org (medicare/medicaid) www.cms.org –www.hhs.org (health & human services) www.hhs.org –www.oig.hhs.gov (inspector general) www.oig.hhs.gov –www.ahrq.gov (agency for healthcare research) –www.medpac.gov (medical payment advisory comm.) www.medpac.gov –www.whitehouse.gov/fsbr/health (statistics) www.whitehouse.gov/fsbr/health –www.div40.org (clinical neuropsychology div of apa) www.div40.org –www.healthcare.group.com (staff salaries) www.healthcare.group.com

95. DPH 2004 Resources (continued) LMRP Reconsideration Process LMRP Reconsideration Process –www.cms.gov/manuals/pm_trans/R28PIM.pdf Coding Web Sites Coding Web Sites –www.aapcnatl.org (academy of coders) www.aapcnatl.org –www.ntis.gov/product/correct-coding (coding edits) www.ntis.gov/product/correct-coding Compliance Web Sites Compliance Web Sites –www.apa.org (psychologists & hipaa) www.apa.org –www.cms.hhs.gov/hipaa. (hipaa) www.cms.hhs.gov/hipaa –www.hcca-info.org (health care compliance assoc.) www.hcca-info.org

96. DPH 2004 Future Perspectives Income Income –Steadier (if economy does not further erode) –Probable incremental declines, up to 10- 20% –If Medicaid dependent (25% or more), then declines could be even higher –Possible “final” stabilization by 2005 Recognition Recognition –Masters Level Psychotherapy?…

97. DPH 2004 Future Perspectives (continued) Paradigms Paradigms –Industrial vs. Boutique/Niche –Clinical vs. Forensic –Mental Health vs. Health –Existing vs. Developing

98. DPH 2004 Future Perspectives Evolving Paradigm = Continued and Significant Change Evolving Paradigm = Continued and Significant Change ARE YOU READY?…