Beginning in 2014 under the Affordable Care Act (aka Obamacare) all new small group and individual market plans will be required to cover ten Essential Health Benefit categories, including mental health and substance use disorder services. Mental health and substance abuse will be covered at parity with medical and surgical benefits. Federal subsidies will help an individual making less than $46,000, or a family of four making less than $94,200 purchase insurance. The government estimates 7 million people will sign up for Obamacare in 2014 and 30 million or more over the next three to five years. So it is likely that mental health professionals will be seeing patients covered by the ACA in the next several years.
Obamacare plans are classified based on premiums and cost sharing. Bronze plans, the least expensive, will pay on average 60% of covered costs with the enrollee responsible for 40%. Silver plans will have a 70/30 split, Gold a 80/20 split and Platinum 90/10. In 2014 the Bronze plans will have a maximum out of pocket cost for health care, aside from insurance premiums, of $6,350 for singles and $12,700 for families.
Specialty care services, including mental health, will be subject to high co-pays. For Bronze plans $70 or $75 copays are likely. For Silver copays will be in the $60 to $65 range.
So, will Obamacare be a net benefit for mental health clinicians? Probably not. Studies show high co-pays are a barrier to care, especially for the sickest patients. The co-pay levels built into the most popular plans, the bronze and silver, will inhibit patients accessing care. The high deductibles will mean that insurance will only pay for a few chronically ill patients with high medical costs.
Meeting deductibles is unlikely for psychotherapy patients because most are comparatively young and likely to be healthy. According to Vessey about two-thirds of psychotherapy outpatients are female and 80% are between the ages of 21 and 50 yrs (Who seeks psychotherapy? Vessey, John T.; Howard, Kenneth I. Psychotherapy: Theory, Research, Practice, Training, Vol 30(4), 1993, 546-553.)
What changes should clinicians make in order to deal effectively with Obamacare?
First, clinicians should make more of an effort to determine what benefits patients have and whether they have met the deductible. Insurance cards will probably have the name of the insurer on the front. You will have to look closely to see if the patient has Obamacare copays and deductibles.
Second, it is in patient’s interest that clinicians file claims because it helps meet the deductible. But, since many patients will not have met their high deductibles, filing claim could be a net burden for the clinician.
Third, clinicians who reduce fees for the uninsured or underinsured may find Obamacare patients still meet their reduced fee criteria. However, using a reduced fee schedule will make it harder for the patient to meet the deductible. Standard fees that can be submitted to insurance with write-offs to reduce the burden on the patient are probably a better way to go.
Fourth, providers sometimes delaying filing claims for patients with high deductibles so the deductible can be met with claims from other providers. This might work sometimes, but timely filing will limit this option.
Overall, the the Affordable Care Act is a misnomer insofar as it concerns outpatient mental health practice.
Some psychologists are increasing their incomes with the new 2013 psychiatric CPT codes. Our data are based on claims paid data from the Carepaths EMR. The findings:
The most frequently paid code in both 2012 and 2013 was for 45 minutes of psychotherapy (90806 in 2012 and 90834 in 2013). Average reimbursement for 45 minute sessions has not changed significantly. However, there are big changes in payment for longer and shorter sessions.
In 2012 the code for a longer session was 90808 (75 minutes). In 2013 the code for a longer session is 90837 (60 minutes). Insurers are paying for 90837 (60 minutes) at a dramatically higher frequency than they were for 90808 (75 minutes). In 2012 90808 represented less than 2% of claims paid and about 2% of revenue. In 2013 90837 represents almost 16% of what gets reimbursed and over 18% of revenue. The amount of the payment for a 90837 in 2013 is less than what was paid for 90808 in 2012, but psychologists come out ahead because they are being paid for longer sessions. Clinicians need to spend 53 minutes with the patient to bill for the longer code in 2013. It is likely that many clinicians are now using 90837 for what would have been billed as a 45 minute session in 2012.
Insurers have dramatically increased reimbursement for shorter sessions. In 2013 reimbursement for 90832 (30 minutes), the replacement for 90804 (20-30 minutes) went from $41.92 to $51.62, about a 23% raise. Clinicians can bill for 90832 as long as they spend 16 minutes with the patient.
Intake reimbursement increased also from $100.81 for 90801 in 2012 to $106.94 for 90791 in 2013, an increase of about 6%.
+90785 (interactive complexity add-on code) is being used and paid for on regular basis although average reimbursement is small, $4.36. The other add-on code +90840 (Crisis) has been used only once in our sample. Either psychologists are not providing the service, are not billing for it, or are not being paid for it.
Psychologists are increasingly using PQRS codes to protect their medicare reimbursement. No psychologists used PQRS codes in 2012. Through August of this year they have used these codes 1406 times. The most used PQRS codes are: G8734 (Elder Maltreatment Screening) 33.3%; G8930 (Assessment of Depression Severity) 27.6%; and G8932 (Suicide Risk) 16.2%.
Astonishingly, Health and Behavior Codes were not used by any psychologist in our database in the year’s 2012 or 2013. These codes became available in 2002 for use by psychologists as a result of advocacy by the American Psychological Association. At the time they were expected to promote integration with primary care services and provide a way for psychologists to be compensated in this arena. But in our sample no psychologist has even tried billing with these codes. Medicare intermediaries and over 50 private insurers pay for them.
Overall, the 2013 cpt code changes are good news for psychologists. There are real opportunities for psychologists to increase their incomes by using 90837 and 90832 more frequently, and by using the add-on code +90785.
Graphs courtesy of Gordon Herz, Ph.D.
Update 11/11/13–We are beginning to hear from clinicians about which insurers pay for 90837 and which ones do not. We will do a furrter analysis of the data to determine which payers reimburse for 90837 and which do not. In the meantime, here are comments from clinicians
“United behavioral health denies claims without authorization for 90837 and refuses to give the authorization unless you use a particular type of treatment that they deem appropriate for only a few diagnoses. They also reduced their reimbursement for 90791 and 90834 as soon as the new codes came out.”
“When our claims were not processed correctly, we contracted Cigna was were told they “made a mistake” in their crosswalk and they have retracted their fee for 90837 and reduced it to 90834. They claim it was not a rate change at all, only a “crosswalk mistake”.”
What an honor Carepaths Inc appointing me as their Chief Medical Officer. Such an exciting time in medical technology, and what a thrill to work with such a forward-looking company!
While we hope our Carepaths team and its products help you render good clinical care, we eagerly want to build a community of practitioners who also find support from one other.
I attended a one-room country school in rural Missouri that still exists today. There were about 25-30 students spread out amongst grades 1-8. Each Friday, we had a spelling bee in the afternoon. The spelling competition was fierce; most students were farm kids who woke up early to do their chores before going to school. Yet, we rallied around each other. We even clapped and yelled when an opposing player got a particularly difficult word correctly.
I hope this blog becomes the afternoon spelling bee where we bring our ideas together, be supportive for one another, and better our practice and the care of our patients and clients.
I look forward to hearing your ideas and experiences. Feel free to email directly at kurt.peters@carepaths.com