{"id":797,"date":"2013-10-31T12:45:58","date_gmt":"2013-10-31T19:45:58","guid":{"rendered":"http:\/\/blog.stevenreidbordmd.com\/?p=797"},"modified":"2013-10-31T12:45:58","modified_gmt":"2013-10-31T19:45:58","slug":"third-party-payment-for-psychotherapy-1-do-you-take-medicare","status":"publish","type":"post","link":"http:\/\/blog.stevenreidbordmd.com\/?p=797","title":{"rendered":"Third-party payment for psychotherapy: (1) “Do you take Medicare?”"},"content":{"rendered":"

\"mcarecard\"<\/a>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. \u00a0Since the clinic accepted Medicare for payment, I did as well. \u00a0I 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.<\/p>\n

I never joined private insurance panels for several reasons. \u00a0As an inveterate do-it-yourselfer, I’ve always handled my own billing and bookkeeping. \u00a0This is considerably harder when multiple health plans are billed, co-payments collected, and so on. \u00a0I like the straightforward way I provide a service, and the person receiving the service pays me directly. \u00a0Somehow it feels more honest than contracting with health plans to funnel referrals my way. \u00a0Private 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.” \u00a0Moreover, since dynamic psychotherapy has always been a big part of my practice \u2014 increasingly so over time \u2014 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. \u00a0Last 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.<\/p>\n

The upshot is that I have a cash-only (or “self pay”) practice, with the exception of my Medicare patients. \u00a0Until this year, Medicare “allowed” 65% or so of my full fee. \u00a0(Medicare sets an allowed fee for a given service, and then pays 50-80% of that. \u00a0I can collect the rest, up to the allowed amount, from a secondary insurer or from the patient. \u00a0This works more or less automatically for secondary insurers, and rather awkwardly when I try to collect from patients.) \u00a0In 2013 the CPT codes<\/a> for psychiatric office visits were revamped. \u00a0This made billing more complicated, and introduced odd, often illogical variations in Medicare and private insurance reimbursement \u2014 sometimes paying more than before, sometimes less.<\/p>\n

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. \u00a0A 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. \u00a0Medicare callers request to see me for medications only, even after I explain this is not the nature of my practice. \u00a0It’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. \u00a0Some 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. \u00a0Clearly, the demand is there, the economic incentive is not.<\/p>\n

Medicare and other third-party payers have a valid need to assure their money isn’t wasted. \u00a0Sometimes 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). \u00a0It’s tempting to protest this, as there’s absolutely nothing inconsistent about treating atypical depression with medication and psychotherapy. \u00a0I could take the time to marshal my arguments, compose a letter, and reveal personal details about my patient to present my case. \u00a0But it’s far easier to resubmit the claim with a slightly upcoded<\/a> diagnosis, e.g., Major Depression, recurrent, mild severity, 296.31, and get paid. \u00a0This uncomfortably clashes with my usual tendency to downcode<\/a> slightly to protect my patient’s confidentiality. \u00a0(Since pressures<\/a> 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. \u00a0Garbage in, garbage out.)<\/p>\n

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. \u00a0Public and private insurers alike sacrifice ecological validity for documentation that appears, but really isn’t, “evidence based.” \u00a0To 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. \u00a0A 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). \u00a0This makes little sense when in many cases the psychotherapy is far more clinically significant than the medications being discussed. \u00a0(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.) \u00a0If 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. \u00a0If this isn’t bewildering enough, some of my colleagues are now doing 52<\/em>-minute sessions, an insignificant increase in duration that qualifies for a different code with much higher reimbursement.<\/p>\n

Since cash-only practice excludes all but the affluent, I view my taking Medicare as a modest concession to avoid elitism. \u00a0I also support a single-payer<\/a> health care system, also known as “Medicare for all,” so participating in Medicare feels like practicing what I preach. \u00a0At 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. \u00a0So far I still answer yes, albeit hesitantly, when asked whether I take Medicare. \u00a0In 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.<\/p>\n","protected":false},"excerpt":{"rendered":"

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 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[7,51,8],"tags":[14,45,61],"class_list":["post-797","post","type-post","status-publish","format-standard","hentry","category-psychiatric-diagnosis","category-psychiatry-in-general","category-psychotherapy","tag-fees","tag-psychiatric-research","tag-third-party-payment","odd"],"aioseo_notices":[],"_links":{"self":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/797","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=797"}],"version-history":[{"count":8,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/797\/revisions"}],"predecessor-version":[{"id":807,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/797\/revisions\/807"}],"wp:attachment":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=797"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=797"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=797"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}