From late 1996 to early 2007 I was medical director of a low-fee mental health clinic where psychiatry residents and psychology interns receive training. Since the clinic accepted Medicare for payment, I did as well. I signed on as a Medicare “preferred provider” and have remained on the panel ever since, even though I left the clinic for full-time private practice nearly seven years ago.
I never joined private insurance panels for several reasons. As an inveterate do-it-yourselfer, I’ve always handled my own billing and bookkeeping. This is considerably harder when multiple health plans are billed, co-payments collected, and so on. I like the straightforward way I provide a service, and the person receiving the service pays me directly. Somehow it feels more honest than contracting with health plans to funnel referrals my way. Private health plans also pay less than usual-and-customary fees and require doctors to share patients’ private details with corporate reviewers to document “medical necessity.” Moreover, since dynamic psychotherapy has always been a big part of my practice — increasingly so over time — I’m sensitive to arguments that third-party payment complicates transference and countertransference, obscures acting-out around payment, and detrimentally takes payment out of the treatment frame. Last but not least, as I’ll discuss mainly in my next post, insurers base reimbursement on a medical model that fits poorly with dynamic work.
The upshot is that I have a cash-only (or “self pay”) practice, with the exception of my Medicare patients. Until this year, Medicare “allowed” 65% or so of my full fee. (Medicare sets an allowed fee for a given service, and then pays 50-80% of that. I can collect the rest, up to the allowed amount, from a secondary insurer or from the patient. This works more or less automatically for secondary insurers, and rather awkwardly when I try to collect from patients.) In 2013 the CPT codes for psychiatric office visits were revamped. This made billing more complicated, and introduced odd, often illogical variations in Medicare and private insurance reimbursement — sometimes paying more than before, sometimes less.
As one of the few private-practice, office-based psychiatrists in San Francisco still on the Medicare panel, I’ve become a magnet for these patients. A local medical center with which I have no affiliation used to refer several callers to me every week, until I sent a letter asking them to please not kill me with their kindness. Medicare callers request to see me for medications only, even after I explain this is not the nature of my practice. It’s more tricky when patients claim to want therapy to get a foot in the door, and then once in my office and now my medico-legal responsibility, confess that they only wanted medication refills all along. Some callers ask to be added to a non-existent waiting list, or to call me every month or two to see if I change my mind about accepting them as patients. Clearly, the demand is there, the economic incentive is not.
Medicare and other third-party payers have a valid need to assure their money isn’t wasted. Sometimes my claims are rejected, as when I received a notice this week that one patient’s diagnosis (Depression Not Otherwise Specified, 311) “is inconsistent with the procedures” I billed (three weekly sessions of moderate-complexity medication management, 99213, combined with 50-minute therapy sessions, 90836). It’s tempting to protest this, as there’s absolutely nothing inconsistent about treating atypical depression with medication and psychotherapy. I could take the time to marshal my arguments, compose a letter, and reveal personal details about my patient to present my case. But it’s far easier to resubmit the claim with a slightly upcoded diagnosis, e.g., Major Depression, recurrent, mild severity, 296.31, and get paid. This uncomfortably clashes with my usual tendency to downcode slightly to protect my patient’s confidentiality. (Since pressures to upcode and downcode routinely distort the documentation of diagnoses in clinical practice, I’m skeptical of all research that uses these diagnoses to derive conclusions about psychiatric practices, disorder incidence, and the like. Garbage in, garbage out.)
Upcoding and downcoding in such cases is not criminal mischief, but an attempt to fit traditional, mainstream psychiatry into a procrustean bed of medical-model diagnosis and procedure coding. Public and private insurers alike sacrifice ecological validity for documentation that appears, but really isn’t, “evidence based.” To take one example, as of this year we must code medication “evaluation and management” separately from the provision of psychotherapy, even if in practice these are done simultaneously and inseparably. A 50-minute psychotherapy session (90836) that includes brief attention to medication (99212) is reimbursed at a much lower rate than the same 50-minute session with more time devoted to meds (99213 or 99214). This makes little sense when in many cases the psychotherapy is far more clinically significant than the medications being discussed. (You’ll note that I think of the psychotherapy code first, but actually it is an add-on to the primary medication “E & M” code.) If medications are not mentioned or evaluated at all, there is yet another code to use for psychotherapy (90834), with an “allowed fee” of $89 for 50 minutes, well below what any psychiatrist or psychologist actually charges. If this isn’t bewildering enough, some of my colleagues are now doing 52-minute sessions, an insignificant increase in duration that qualifies for a different code with much higher reimbursement.
Since cash-only practice excludes all but the affluent, I view my taking Medicare as a modest concession to avoid elitism. I also support a single-payer health care system, also known as “Medicare for all,” so participating in Medicare feels like practicing what I preach. At the same time, it’s easy to see why most of my office-based colleagues opt out of Medicare: lower pay for more paperwork, rules that don’t make sense, and various factors that make dynamic psychotherapy harder to conduct and be paid for. So far I still answer yes, albeit hesitantly, when asked whether I take Medicare. In my next post I’ll expand these ideas into private insurance for outpatient psychiatry, including whether dynamic psychotherapy resembles a medical intervention enough to fit a “medical necessity” model.