The National Psychologist
620-A Taylor Station Road
Gahanna, Ohio 43230
Phone: 614/861-1999 Fax: 614/861-1996 - For additional information contact Martin A. Saeman, Managing Editor

Medicare to cut mental health payments by 9 percent

By Richard E. Gill, Assistant Editor
Mental health providers and other health services will be hit this year by a 9 percent decrease in Medicare reimbursements that could have a devastating effect on mental health care.

A deeper 14 percent reduction was scheduled, but a lame-duck U.S. Congress voted in December to eliminate 5 percent of the reduc­tion - the share attributed to the "sustainable growth rate" (SGR) formula justified as a means to keep Medicare solvent for the long run.
"Preventing the SGR cut is an important victory for APA and other provider groups that were working in the closing hours of this Congress," said Russ Newman, Ph.D., J.D., APA's executive director for the Practice Directorate.

"Unfortunately, despite considerable effort, we were unable to gain inclusion in this legislation a provision to block the additional 9 percent cut scheduled for mental health services, which is occurring through the Centers for Medicare and Medicaid Services' (CMS) `five­ year' review regulation that was finalized in November."

However, Newman added, the incoming Congress has indicated a willingness to look closely at ways to improve Medicare over the next year. APA will attempt to have full reimbursements restored retroactive to the first of the year, he said.

Luana Bossolo, assistant executive director of public relations for APA, said the cuts would impact provider reimbursements and Medicare patient access to the services that psychologists provide. It will also impact other consumers.

Because of that, "This has been a front-and-center issue for APA. We realize this could have a serious effect, definitely," she said. Sources of income for psychologists and other mental health providers will dry up because of a reduction in Medicare reimbursement.
Alice Randolph, Ed.D., M.S., federal advocacy coordinator for the Ohio Psychological Association, called the reduction, "the most bizarre and unintended consequence of a public policy I have ever seen in my life, and I've seen a lot of them."

Psychological services are hit hardest by the CMS changes, which took effect Jan. 1. Randolph said psychology would feel the impact of the Medicare cuts more than most other health services, which are not subject to the same percentage of cuts under the policy change as are mental health services.
"It's a further blow to mental health services." Randolph said.

Those hit hardest by the decrease are the elderly, she said. For the most part, mental health care for geriatrics is based on "Medicare allowable," and it's the allowable that has been reduced by 9 percent.

"It probably means that those with the least access are going to be limited even more," Randolph said. "Because of the reduction, psychologists are not likely to drive to rural areas to treat patients in senior centers, so the result is a reduction in salary and a reduc­tion in the care of elderly patients."
What Congress has done, maintained Randolph, is penalize the very people who are most in need. Medicare will not pay for treat­ments such as face-to-face sessions with therapists. Those relationships are likely to be reduced or done away with.

"The irony of this is the very thing they want to take more care of, which is supposed to help tie into the health care provider, they are de facto making it harder for the people who are most professional and that is psychologists," Randolph said.

Since other health services are not affected as harshly as psychology, and therefore will not be inclined to work as hard to roll back the reduction, Randolph said it would take a coordinated effort by psychologists around the country to fight the Medicare reduc­tion with the incoming Congress.

To join in the fight to roll back the reductions or for additional information about the Medicare cuts contact Randolph at Alicerandolph@psychtransitions.com

Samuel Knapp, Ed.D., director of professional affairs with the Pennsylvania Psychological Association, said the 9 percent reduc­tion is substantial. "It's going to be harmful. Consumers will have fewer options and fewer people will be willing to accept Medicare. This is not only in psychology, but in all other kinds of health care as well."

Knapp said hospitals do not have a large profit margin, and Pennsylvania has the third largest population of older adults in the country. "Hospitals have a I or 2 percent profit margin and to have a cut in Medicare like this is going to be very substantial for them. Some of them simply won't accept Medicare patients," he said.

A consensus is that psychologists will reduce their caseloads or leave Medicare altogether.
This article originally appeared in the January/February 2007 issue of The National Psychologist, 620-A Taylor Station Road, Gahanna, Ohio 43230. Subscriptions are available for $35 for one year or $60 for two years. Reprinted with permission

The National Psychologist
620-A Taylor Station Road
Gahanna, Ohio 43230
Phone: 614/861-1999 Fax: 614/861-1996
 For additional information contact Martin A. Saeman, Managing Editor

Prognosis not all bad for Medicare fees
By Paula Hartman-Stein, Ph.D.
In coping with the pending 9 percent Medicare reductions psychologists can take hope from the adage: "It's always darkest before the dawn" - and some practitioners say a new dawn is coming.

Psychologists are not the only healthcare professionals to suffer the lower reimbursements. "Everyone is taking a hit," said James Georgoulakis, the APA representative to the Relative Update Committee of the American Medical Association.

"It is pure BS that money is taken only from psychology to fund Evaluation and Management (E&M) Services Codes available to physicians," Georgoulakis said. "We have a pot of money allocated by Congress to pay for Medicare services so when certain clinical codes have an increase in their work value, the monetary value of other codes is reduced to keep the overall budget the same," he said, explaining that Congress mandates Medicare's budget neutrality, also known as a zero sum game.

On Dec. 9 Congress passed the Tax Relief and Health Care Act of 2006 (HR 6111), resulting in a last-minute elimination of the 5 percent cut under the Sustainable Growth Rate formula.

Before that, psychologists expected cuts as deep as 14 percent and a significant number of them considered opting out of Medicare, according to an Internet survey of 498 psychologists conducted by the National Alliance of Professional Psychology Providers (NAPPP).
John Caccavale, Ph.D., director of NAPPP, said only slightly more than a third of the psychologists said they would continue to take Medicare patients. "The survey is not a random one so the exact percentage of psychologists expecting to leave Medicare is unclear, but it would be significant and will impact the program," said Caccavale.
But gloom and doom predictions about additional reductions in fees for mental health services under Medicare may be premature.
According to Georgoulakis, "Many psychologists are taking a short-sighted view of the situation. Temporarily it looks bad for the patient and the doctor, but the fact that E&M codes received an increase in their work values signifies the start of future improvements of the value of other cognitive services," he said.
In past years Centers for Medicare and Medicaid (CMS) has made retroactive reimbursement increases as a result of adjustments to practice expenses for clinical services and pressure from members of Congress. "We do not have final, final amounts of reimburse­ment for all of the codes open to psychologists for 2007," said Georgoulakis. "We are never finished."
According to Joe Casciani, Ph.D., senior vice president of VeriCare, a company headquartered in San Diego that hires psycholo­gists for long-term care facilities, "Psychologists need to do a much better job showing the value of behavioral health services in order to gain better reimbursement."
The Tax Relief and Health Care Act includes a provision for a 1.5 percent bonus-incentive payment for the second half of 2007 for providers who voluntarily meet quality measures determined by the CMS.
According to a Congressional Research Service report for Congress updated Dec. 12, a number of government-sponsored pay for­ performance initiatives are currently under way in physicians' offices, hospitals and nursing homes.
Nick Cummings, Ph.D., past president of APA, said, "The future of healthcare reimbursement will become increasingly perfor­mance-based, something that good, effective clinicians do not have to fear. The hope is that one day we will be freed from arbitrary, picayune bean-counter case management and rewarded for producing successfully on behalf of our patients. The only casualties will be marginal, ineffective providers who drain the healthcare system without results."

Paula Hartman-Stein, Ph.D., is a clinical psychologist and consultant at the Center for Healthy Aging in Kent, Ohio. Past president of the Society of Clinical Geropsychology ofAPA, she is involved in advocacy efforts on a regional and national basis. She can be reached
through her website, www.centerforhealthyaging.co
This article originally appeared in the January/February 2007 issue of The National Psychologist, 620-A Taylor Station Road, Gahanna, Ohio 43230. Subscriptions are available for $35 for one year or $60 for two years. Reprinted with permission from The National Psychologist.

MORE NEWS

By New York Times:
May 25, 2006
The Check Is Not in the Mail
By MILT FREUDENHEIM Correction Appended
http://www.nytimes.com/2006/OS/25/business/25insure.html?ei=50...
Few things rankle a doctor more than an insurance company's saying it cannot find a claim for medical services. Particularly when there is even a signed return receipt to document delivery of the bill.
"We actually had the little green card to show who signed for the dang thing," said Elizabeth Wertz, chief executive of the Pediatric Alliance, a large group of Pittsburgh doctors. "We sent it by certified mail. The insurance company said they didn't have it."
The claim was for several thousand dollars, according to Ms. Wertz, who declined to identify the company, a large regional insurer, for fear of making it more difficult to wrangle payments. It is a problem known to many doctors as they struggle to balance the rising cost of providing patient care with what they see as a reluctance by some powerful insurers to pay promptly.
Pediatric Alliance's 37 doctors are among the 7,ooo physicians, nurse practitioners and other health care providers around the country who are clients of the claims-processing company Athenahealth, which plans today to present a rare warts-and-all look at how well - or not - the nation's seven biggest health insurers pay their bills.
Not well enough, in many cases, according to the data and to experts who say the survey provides the most comprehensive look yet at the state of accounts payable vs. accounts receivable in the nation's health care system.
Tardiness or refusal to pay what doctors consider legitimate medical claims may add as much as 15 to 20 percent in overhead costs for physicians, forcing them to pursue those claims or pass along the costs to other patients, according to Jack Lewin, a family doctor who is chief executive of the California Medical Association, a professional group of 35,00o physicians.
Weighing all the factors in the survey, Athenahealth gave Humana the top overall ranking, closely followed by the federal Medicare program. The federal insurer for military families, Champus/Tricare, was in sixth place, with the commercial insurer WellPoint ranked last.
But because of all the caveats required to understand and justify those overall rankings, experts said the more useful comparative look might be at individual categories - like average number of days between the medical service and the payment. By that measure, Humana's 29.o days was quickest and Champus/Tricare's 41.4 days was slowest. The company said it had already alerted some of the insurers to problems that showed up in the survey.
The survey, an analysis of more than five million line items from health insurance claims submitted in the last three months of 2005, sheds light on the challenges that doctors and their patients face in getting their bills paid.
"We all pay that cost," said Dr. William F. Jessee, a pediatrician who is president of the Medical Group Management Association, a trade group of 20,000 office managers for about half the nation's doctors. "It winds up getting passed on to consumers and employers who purchase health insurance."
The data may also provide the glimmer of an answer to a seeming conundrum: How is it, as the nation staggers under growing health care costs, that the commercial insurers responsible for paying much of the bill tend to be highly profitable and have stocks that are performing well? Tight-fisted approaches to paying bills may be part of the answer.
Athenahealth concedes that its survey, while broad and fairly representative of a cross section of the nation's doctors, is not statistically scientific. That is a limitation that We1lPoint, the nation's largest commercial insurer, quickly pointed out in saying that its own poor showing was unjustified. The survey indicated, among other things, that WellPoint got relatively poor marks on lost bills and delays in payments.
The survey did rate We1lPoint relatively high in one category: clearly explaining the reasons claims were denied.
Most of the other national insurers in the report, which also included Aetna, UnitedHealth Group and Cigna, regardless of how they fared, acknowledged the survey as a unique and potentially useful snapshot.
"Athenahealth's report provides some common metrics that will be useful for future benchmarking," said Wendell Potter, a Cigna spokesman. "Making improvements for all payers is likely to be a work in progress for some time to come."
Phil Pead, the chief executive of Per Se Technologies, a large claims-handling company that - unlike Athenahealth - is paid by insurers as well as care providers, said errors made by doctors' offices also accounted for a large share of their problems in being paid. "About 40 percent of denials occur because of incorrect information - the wrong insurance card or address or other information," he said.
Athenahealth, which says it collected $1.8 billion on behalf of its physician clients last year, is among the biggest of several thousand companies that help doctors and hospitals get paid by editing their claims and helping them to deal with difficult cases. Health care providers who can afford such services say they have become a necessary part of doing business.

In the case of Pediatric Alliance, with 37 pediatricians in a dozen offices in and around Pittsburgh, the doctors' group spends at least $250,00o a year on salaries for eight billing clerks who handle claims and pursue money owed by insurers and patients. That is on top of salaries in Pediatric Alliance's offices for staff members to verify the patient's coverage and collect co-payments, plus paying an outside company to check for errors before the bills go out.
Ms. Wertz, the alliance's chief executive, says some insurers' telephone call centers limit claims-related issues to io per call. "That's incredibly inefficient," she said. "We see thousands of patients. Our people have to sit on phone 30 minutes to get a live person."
Athenahealth's other measurements included the percentage of claims paid without changes within 9o days. Medicare came in first, at 92 percent. Champus/Tricare was last, at 85.1 percent.
In the category of "lost" claims, Humana tied with Aetna with only 0.2 percent lost and Cigna was worst 1.3 percent.
The results are to be posted for public viewing today on a new Web site, www.athenaPayerView.com, and revised every three months. Physicians Practice, a trade magazine owned by MediQ, a health care publishing company, is also reporting on the Athenahealth results next week. (Although MediQ also publishes a quarterly magazine for Humana, that insurer was treated no differently from any other in the survey, Physicians Practice said in an advance copy of its article.)
"We are very pleased by the outcome," said Bruce Perkins, a senior vice president at Humana, which fared relatively well in the survey.
Herb Kuhn, director of the federal Center for Medicare Management, a division of the Centers for Medicare and Medicaid Services, said he hoped the survey would prompt commercial insurers to speed their payments to doctors by putting public pressure on them. "This is critical to these folks in managing their competition," Mr. Kuhn said.
But We1lPoint, the nation's largest commercial health insurer, dismissed the Athenahealth findings. The report has "absolutely no statistical significance," said James Kappel, a WellPoint spokesman.
He said the number of WellPoint claims in the report was "very small compared with the total number that WellPoint alone processes."
Athenahealth said it analyzed 266,914 line items from its clients' claims with WellPoint during the last quarter of 2005. That would be only a tiny fraction of WellPoint's average of about 60o million line items per quarter, according to Mr. Kappel.
The UnitedHealth Group, the second-largest commercial insurer, tended to rank toward the top of most of the survey's categories, but raised doubts about the findings. "We are pleased that Athenahealth had fairly positive readings of our provider payment practices," said Mark Lindsay, a UnitedHealth spokesman, "but we do not believe the study is truly representative of our business."
Nancy Brown, Athenahealth's senior vice president for clinical service development, acknowledged that "it is not a statistically valid sample."
"But in any given market," Ms. Brown said, "we generally have a relatively good range of medical specialties."

Athenahealth's 7,000 physician clients in 31 states represent about 2 percent of the nation's 450,00o active doctors, according to Eric Brown, a research director at Forrester Research. The company says its customers are mainly small practices with one or two doctors but some have as many as 400 physicians, and clients include doctors in cities, suburbs and small towns.
Doctors in a number of states said they welcomed the Athenahealth report, which also compared dozens of regional insurers around the country. Dr. Molly Katz, a Cincinnati gynecologist and former president of the Ohio Medical Association, said she hoped the publicity would encourage insurers to improve their payment practices.
"I would much rather have my staff talking to patients than talking to insurance companies," Dr. Katz said.
Correction: May 26, 2006
An article in Business Day yesterday about a survey of health insurance companies and how promptly and completely they pay claims gave an incorrect address for a Web site that posted the results. It is www.athenaPayerView.com, not www.athenaPayView.com.

Copyriqht 2006 The New York Times Company