A new public comment process could expand the type and frequency of psychological and medical services that Medicare will cover for older adults and people with disabilities.

The comment process, mandated by the U.S. Department of Health and Human Services' Centers for Medicare and Medicaid Services (CMS), requires all Medicare carriers to allow the public to review and comment on the guidelines they use to determine whether medical and psychological services are covered. That new comment period opens the door for psychologists to explain why behavioral services are an important part of many Medicare recipients' care.

"This is a wonderful opportunity for psychologists to have a voice in Medicare policy," says Forrest Scogin, PhD, a member of APA's Committee on Aging (CONA), which is tracking the progress of the new public comment process and its impact on local policies. "Many patients rely heavily on Medicare for access to services, and we know that there are psychological services that can be beneficial for [them]. Unless we advocate for their inclusion, we lose out on opportunities to provide services, and the patients are deprived of the use of those services."

The public comment process applies to the thousands of guidelines that individual Medicare carriers establish to determine reimbursement for services, ranging from psychological assessments to physical therapy to cataract surgery. These guidelines, called Local Medical Review Policies (LMRPs), vary by state. During the review period, the carrier is now required to post the draft LMRP on a CMS-run Web site (www.draftlmrp.net).

CONA members say that if mental health professionals take advantage of the new public comment process, they could make a substantial difference by lobbying for needed psychological services for older adults and their caregivers.

The new rules not only allow psychologists to educate their Medicare carriers about the importance of these services but also to educate themselves about the LMRP process so that they can properly bill and be reimbursed by Medicare, says Diane Pedulla, JD, director of regulatory affairs in APA's Practice Directorate.

"The LMRP may contain nuances that are critical to accurate billing for services," Pedulla explains. "The LMRPs typically provide more information than is listed in the American Medical Association's billing codes, such as requiring extra documentation."

Psychologists in New York are already taking advantage of the new federal rules by working with their state's Medicare Carrier Advisory Committee (CAC), the group of physicians and other stakeholders that drafts LMRPs and accepts the public's comments.

Last year, for example, the New York State Psychological Association (NYSPA) and its members used their long-standing relationship with the state's CAC to help redraft the state's LMRP on mental health coverage to recognize the importance of mental health services for Medicare recipients, including coverage for those in the early stages of dementia or Alzheimer's disease and appropriate treatment for individuals with serious mental illness.

Initially, the draft policy stipulated that psychological services had to be prescribed and supervised by a psychiatrist, required that patients with depression take medication in order to have psychotherapy, and recommended extremely limited treatment sessions for major psychological disorders.

"We had negotiated our previous LMRP very successfully, so it was extremely unsettling when we received a potentially devastating new policy draft in 2000," explains NYSPA legislative chair Eric Garfinkel, PhD. He and Frank Goldberg, PhD, led a cadre of psychologists concerned about the possible effect of these regulations. They compiled psychological research to show why mental health services are important for older adults and people with disabilities, and wrote a suggested revision of the LMRP.

"We gave them a carefully constructed and comprehensive alternative draft and a thick binder full of supporting documentation," Garfinkel says, noting that the carrier was probably receptive to their suggestions because NYSPA psychologists have been working alongside the state's CAC for years. Garfinkel, Goldberg and their colleagues have attended almost every LMRP meeting, not just those that address mental health concerns.

"Demonstrating our commitment and respect for the process," says Garfinkel, not only helped to establish a strong working relationship, but also allowed them to learn more about how the carrier does business. "You have to help the carrier do its job," he adds, explaining that it's important to understand the forces that can influence the carrier's decisions. "Don't complain about the policy--help them write a new one."

To help others emulate New York's success, CONA and APA's Office on Aging are developing a tool kit that will include information about LMRPs, how CAC meetings work, literature citations for the importance of psychological services for older adults--especially for dementia and Alzheimer's patients--and examples of some successful advocacy efforts. The kit should be available this spring through APA's Office on Aging.

Further Reading

For more information, contact Deborah Digilio, APA's Office on Aging, at (202) 336-6135; e-mail, or APA's Medicare Information Network at (202) 336-5800; e-mail: Practice.