With tenacity and support from APA's Practice Directorate, psychologists in several states have challenged attempts by insurance carriers to place restrictions on the delivery of services to Medicare beneficiaries. They've done this largely by helping to develop or clarify local medical review policies (LMRPs), which provide guidelines for coverage, according to Diane Pedulla, JD, director of regulatory affairs for the APA Practice Organization.
"Because the Center for Medicare Services issues relatively few national coverage decisions, most parameters on Medicare services are set by insurance carriers through LMRPs," says Pedulla. "By commenting on draft LMRPs, psychologists are taking a proactive approach and alerting carriers to their concerns before the policies become effective."
In California, language in National Heritage Insurance Company's (NHIC) draft psychotherapy LMRP regarding patients with dementia was rigid and generally reserved reimbursement for psychotherapy services for psychiatrists only. In fact, the draft claimed that psychotherapy was inappropriate for patients with dementias and other organic conditions that affect cognition, says Charles Faltz, PhD, director of professional affairs for the California Psychological Association.
"There was very little knowledge of the value of psychology with these patients," says Faltz. Armed with psychological research on the effectiveness of psychotherapy for people with dementia, he suggested revisions to the draft that would expand the guidelines for psychotherapy with patients with dementia and increase the number of sessions available for patients in nursing homes. NHIC accepted the revisions and an updated policy became effective in September.
For their part, Pennsylvania, New York and New Jersey psychologists were also concerned with LMRP language in their states, though for a slightly different reason.
Last year, Pennsylvania psychologists began working with the Medicare carrier in their state, HGS Administrators, to develop guidelines for using health and behavior codes. These codes are used to reimburse psychologists for treating psychological aspects of physical illness--for example, the management of diabetes.
The LMRP was developed and finalized in June. But some of the language in the Pennsylvania policy is ambiguous, says Sam Knapp, EdD, director of professional affairs for the Pennsylvania Psychological Association (PPA). Some people interpreted the policy's wording to mean that psychologists could not be reimbursed for treating patients with co-existing physical and mental illnesses.
After some wrangling with the carrier's medical director, PPA got clarification in writing that says as long as the primary diagnosis billed to Medicare is a physical diagnosis, psychologists can get reimbursed under psychotherapy codes for services provided for the patient's mental health disorder. That way the health and behavioral intervention would be the primary diagnosis, not the mental health disorder, says Knapp.
Eventually, he says, the Pennsylvania carrier will revise the Health and Behavior Code Bulletin to reflect this clarification. Though in the meantime, psychologists there are using health and behavior codes and are being reimbursed for services provided to patients with a physical diagnosis.
Other insurance carriers used the Pennsylvania LMRP as a template--including Empire, a New York and New Jersey Medicare carrier. Consequently, psychologists in those states also argued for a revision to the health and behavior policies to clarify this misinterpretation.
"PPA addressed the problematic language with the Pennsylvania carrier, and although our input was well received, the necessary changes were not published in written form," says Eric Garfinkel, PhD, a member of APA's Medicare Task Force and the New York State Psychological Association, as well as PPA. "Meanwhile, other carriers copied the problem language and now these states' psychological associations have had to confront the same issues," he says. The New York and New Jersey psychological associations submitted joint comments on the draft LMRP.