The COVID-19 public health emergency has increased demand for mental and behavioral health services at the very time it has driven most of those services to telehealth platforms. In response, APA has led a successful advocacy and education campaign to maximize the availability of telepsychology services for vulnerable populations and to ensure that psychologists are prepared to provide these services and are properly reimbursed for them.
APA’s campaign began in full force on March 10, as part of its annual Practice Leadership Conference. APA members and staff conducted 250 congressional visits by phone and in-person, lobbying for support of telehealth services.
“Three weeks later, in the thick of a public health emergency, a group of APA staff and leaders in the field delivered a method and payment policy that allows for the provision of telepsychology services,” says Antonio E. Puente, PhD, co-chair of APA’s Advocacy Coordinating Committee and a former APA president. “From an idea to a reality in three weeks is a miracle, and it is a bright light that interfaced practice, policy and advocacy.”
Several key changes resulted from APA’s advocacy. They include changes to:
Medicare
On March 19, the federal government designated psychologists as critical, essential workers in the U.S. response to COVID-19. As such, the Centers for Medicare & Medicaid Services (CMS) improved access to care for Medicare beneficiaries by:
- Setting up advanced and accelerated paymentsopens in new window to help with cash flow challenges.
- Easing the enrollment proceduresopens in new window for new providers by waiving certain requirements and expediting new applications.
- Granting exceptions and giving providers extra timeopens in new window to meet Medicare’s quality reporting requirements, such as the Merit-based Incentive Payment System (MIPS), during the public health emergency.
In addition, under the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020opens in new window, CMS issued further guidance based on APA recommendations to waive key telehealth requirements and allow psychologists to provide most of their typical services via audio-only telephones. Both new and existing Medicare beneficiaries can receive expanded telehealth services from their homes.
The ability to work from home. Psychologists can provide an expanded portfolio of services from their own homes using either audio-only telephones or through traditional telehealth with audio and video functions that provide two-way, real-time interactive communication.
“To curb the spread of the coronavirus and help our communities heal, we cannot leave any of our neighbors without access to videoconferencing technologies behind,” says Arthur C. Evans Jr., PhD, APA’s CEO. “Psychologists can now use their specialty skills to improve the health of all the communities we serve.”
The U.S. Department of Health and Human Services (HHS) is also waiving potential penalties for violations of the Health Insurance Portability and Accountability Act (HIPAA) for providers who use telehealth to treat patients during the crisis. HHS specifically referenced Skype, FaceTime and other noncompliant telehealth platforms as reasonable options to provide care. “While penalties are being waived at the federal level for non-HIPAA compliant telehealth platforms, it is still best practice to choose one that is compliant,” notes Deborah C. Baker, JD, APA’s director of legal and regulatory policy. “Preferably one that offers a business associate agreement and that you can use beyond the public health emergency.”
Billing. Psychologists should bill Medicare for telehealth services in the same way that they would have for face-to-face services—and they should expect to be reimbursed for the same dollar amounts. During the crisis, psychological and neuropsychological testing, health behavior assessment and intervention, and group psychotherapy can now be billed through telehealth. Additional restrictions have been waived regarding visits to inpatient units, skilled nursing facilities and nursing homes. The telehealth services covered by Medicare during COVID-19 fall into two categories:
Services Allowed via Phone and Traditional Telehealth
- Psychiatric diagnostic interview (90791, -92)
- Psychotherapy, including individual (90832, -34, -37), group (90853), family (90846, -47) and psychotherapy for crisis (90839, -40)
- Psychological and neuropsychological testing (96130–96133 and 96136–96139)
- Health behavior assessment and intervention services, individual and group (96156, -58, -59, -64, -65, -67, -68, -70, -71)
- Psychoanalysis (90845)
- Neurobehavioral status examination (96116, -21)
- Interactive complexity (90785)
- Behavioral Screening (96127)
- Screening, Brief Intervention, and Referral to Treatment (G0396, G0397)
- Developmental Screening and Testing (96110, -12, -13)
- Adaptive Behavior Assessment (97151, 97152, 0362T)
- Adaptive Behavior Treatment (97153-97158, 0373T)
New ways of communicating. CMS has expanded the types of communication available to Medicare beneficiaries during this time period by activating reimbursement for two sets of additional Current Procedural Terminology (CPT) codes: (1) telephone assessment and management services and (2) e-visits.
- Telephone assessment and management services are provided by a psychologist when a patient calls and the psychologist assesses the patient, then provides an intervention service on the spot. These services, and their accompanying codes, do not replace traditional psychotherapy and reimburse at a lower rate because they were built for brief and directed services.
- E-visits are patient-initiated digital communications conducted through electronic health record portal messages or other HIPAA-compliant, secure platforms that require professional patient assessment and decision-making to direct subsequent management of the patient.
For additional specifics on how to bill telehealth services, telephone assessment and management services and the new e-visit coverage for Medicare, see the expanded coverage on the APA Services website.
State regulations
Unfortunately, the new federal legislation applies only to Medicare beneficiaries and cannot supersede state licensing laws. For example, licensed psychologists are typically prohibited from using telehealth to provide services across state lines. To encourage states to adopt more telehealth-friendly legislation, APA drafted letters to private insurers, state regulators and governors in all 50 states to be delivered in partnership with state psychological associations. The letters urge state officials to temporarily suspend state licensing laws and regulations regarding telepsychological services to ensure continuity of care and to avoid spreading the virus. This would include approving videoconferencing for all providers without limitation, as well as telephone-only services, interprofessional consultation and the elimination of barriers for existing telehealth coverage.
Many state governors quickly responded to the APA/state psychological association letters by issuing emergency orders to increase access to telehealth services and to increase the pool of available health-care providers. Within weeks:
- 12 states issued executive orders calling for expansion of telehealth service rates to be comparable to in-person service rates.
- 14 states issued executive orders allowing patients to receive telehealth services in their own homes.
- 16 states temporarily lifted licensing requirements.
- 22 states either expanded their policies for out-of-state providers to temporarily practice in their states or instituted emergency expedited registration for out-of-state providers.
“We continue to urge each jurisdiction to reimburse the full range of psychological services via telehealth and are following up with additional efforts in those states where expanded coverage is still needed,” says Baker.
Find out where your state stands on telehealth by reading APA’s resource summarizing the current state emergency orders.
Resources for psychologists
In tandem with its advocacy work, APA has ramped up education and communications efforts to ensure that the telehealth services psychologists are providing are of the highest possible quality.
“While some psychologists have experience providing psychotherapy services via telehealth, for many this may be the first time they are attempting to serve their patients in this way,” says Jared L. Skillings, PhD, ABPP, APA’s chief of professional practice. “By partnering with leaders in the field and other organizations, we have worked to quickly provide resources to educate psychologists on how to best provide a wide variety of psychological services via telehealth.”
Psychologists who are new to telehealth can build their competence by studying APA’s Guidelines for the Practice of Telepsychology or taking a relevant course. APA has also developed an office and technology checklist for telepsychological services to help psychologists and their patients prepare for telehealth sessions, including by using an informed consent document.
APA has also developed guidance for psychologists who work remotely in specific settings or with patient populations including:
- In nursing homes
- With children and adolescents, for testing
- With those experiencing pain, preparing for surgery or with obsessive-compulsive disorder
- When conducting psychological assessment or neuropsychological assessment
- In group therapy
With all these changes, it is expected that psychologists might have questions like what to do if they might be infected or under what circumstances should one provide in-person services.
Finally, here are concrete strategies for psychologists to use to manage their stress during this challenging time.
