More psychologist rate cuts

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Psychology associations allege deep Humana rate cuts violate parity
Joint letter signed by APAPO is part of broader reimbursement advocacy strategy
By Legal and Regulatory Affairs staff
From the APAPO

July 16, 2012—On July 6, the APA Practice Organization (APAPO) and ten state psychological associations sent a letter to the federal agencies that regulate parity, the Departments of Health & Human Services, Labor and Treasury. The letter asserts that unprecedented rate cuts over the last few months by Humana and its behavioral health subsidiary LifeSynch violate the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).

The letter by APAPO and the state associations for Georgia, Colorado, Florida, Indiana, Minnesota, Ohio, South Carolina, Tennessee, Texas and Utah was signed by APAPO’s Executive Director for Professional Practice Katherine C. Nordal, PhD and representatives of each association. The letter responds to Humana’s announcing that it will reduce rates for psychologists in those states to $56 to $58 for 45-50 minutes of psychotherapy under code 90806.

In Georgia, where Humana had been one of the highest reimbursers in the state, the rates were slashed almost in half. In other affected states, the cuts ranged from 40 percent down to 12 percent. These latest cuts follow similar Humana cuts last year in Ohio, Florida and Illinois. As stated in the letter, “Humana now has a commanding lead in the nationwide ‘race to the bottom’ in mental health reimbursement rates, a race started last summer by Blue Cross Blue Shield (BCBS) of Florida.”

Nordal and the state associations expressed their concern that the cuts would devastate patient access to mental health care and eviscerate all other protections under MHPAEA. The organizations supported these concerns citing data from surveys showing that prior rate cuts (discussed below) substantially impaired patient access to care.

The organizations argue that Humana’s deep cuts targeting mental health reimbursement rates violate the non-quantitative treatment limitation (NQTL) provisions of the Interim Final Rule (IFR) under MHPAEA. The NQTL provisions require that standards for provider admission to participate in a network, including reimbursement rates must be comparable to those standards for medical and surgical services. Absent evidence that Humana has cut medical/surgical rates, the letter argues that this is a clear parity violation.

Recent APAPO reimbursement advocacy efforts
The July 6 Humana letter is a part of APAPO’s larger reimbursement advocacy efforts on a variety of fronts involving both private and public insurers. In April 2012, before the latest round of cuts, APAPO and the Illinois Psychological Association (IPA) wrote a letter (PDF, 38KB) to the director of the Illinois Department of Insurance requesting investigation of an apparent parity violation by Humana after the company sent 90-day termination letters in late March 2012 to Illinois practitioners who had not signed new provider contracts that lowered reimbursement rates for 90806 to $58, a rate cut of 42 percent. (Because Humana’s Illinois rate cut is before the Illinois regulators, APAPO and IPA decided that IPA should not participate in the July letter to the federal regulators.)

The APAPO’s major parity challenges to rate cuts began in October 2011, when APAPO and the Florida Psychological Association sent a joint letter (PDF, 140KB) to the federal agencies responsible for enforcing mental health parity alleging that CBCS of Florida’s proposed 33 to 54 percent cut in reimbursement rates for psychologists is a violation of federal parity law.

The two organizations followed on March 23, 2012, with an urgent request to Florida insurance regulators to address state law violations such as failure to pay psychologists for over three months in violation of the prompt payment law while federal regulators investigated the federal parity issues.

Some of the APAPO letters discussed above have resulted in agency investigations which are currently in progress. The agencies have indicated that they can better perform their investigation outside of the spotlight and accordingly have asked that we not provide details regarding the investigation to our membership. We will provide further information when we are able to do so.

APAPO continues to press for fair and adequate reimbursement for psychologists in both the private sector and Medicare, and we will continue to inform members about significant developments through our PracticeUpdate e-newsletter and other vehicles.

If you are aware of a major rate cut involving psychological services, or for more information, please contact the Legal and Regulatory Affairs office by email or at (202) 336-5886.

That kind of blows.

Sidenote: Edieb, how is the psychopharm training going?

So does this involve private practice only?

It never involves private practice only. Your salary at a hospital, et cetera, is based on how much your employer can bill for your services. The less insurance pays, the less you make. This is one reason why the V.A. is phasing out psychologist positions with LPCs: We can't bill enough to justify our "high" salaries.

I am preparing to take the PEP, the test allowing me to prescribe in September-October. On a related note, the Coast Guard is now also hiring prescribing psychologists and one state in the Northeast is very close to passing RxP but is taking a stealth mode approach akin to what was taken in Louisiana. Just because you don't see much activity occurring in regards to RxP, doesn't mean there isn't activity.

If Humana want's to cut rates, why don't psychologists just not resign with them? They will have a huge shortage of psychologists and be forced to raise rates. Seems like supply and demand would work itself out here.

Many psychologists have left insurance all together. I'd expect even more to leave (at least that is the trend w. many specialty areas).

How do they get paid, then? Sliding fee scale?

Originally Posted by cara susanna

How do they get paid, then? Sliding fee scale?

I'm pretty sure most of them charge significantly more than what the insurance rates would cover (but perhaps do some sliding scale as well). There apparently is a segment of the population out there willing to pay out of pocket for services, but I certainly have never met any of these folks.

Originally Posted by cara susanna

How do they get paid, then? Sliding fee scale?

There are a number of ways....EAP contracts, fitness for duty eval w. the local/ state police, individual provider agreements (1 time contracted rates w. insurance companies who lack adequate in-network coverage). I am biased towards eval, but there are therapy alts too (EAP is a popular one). Reimbursement ranges quite a bit, so not all are good contracts/agreements. A great way to built stability inPP is through retainer fees, but you need to have a niche for a company to be willing to pay it.

Originally Posted by Pragma

I'm pretty sure most of them charge significantly more than what the insurance rates would cover (but perhaps do some sliding scale as well). There apparently is a segment of the population out there willing to pay out of pocket for services, but I certainly have never met any of these folks.

I think one of the more common setups, at least that I've seen/heard, is to have the patient pay out of pocket, and then the provider will offer to supply any needed paperwork so that the patient can apply for recompense him/herself from the insurance company.

Nearly every other neuropsych case I worked on in grad school was either a vocational rehabilitation referral (paid by the state), a forensic case (paid by the lawyer), "indigent" care (free), or at the university clinic (significantly-discounted price that was paid out-of-pocket).

Originally Posted by AcronymAllergy

Nearly every other neuropsych case I worked on in grad school was either a vocational rehabilitation referral (paid by the state),

My understanding is that these can be terrible reimbursements as well...but I am sure it varies...

Originally Posted by AcronymAllergy

a forensic case (paid by the lawyer),

I hear this is where the money is...

Originally Posted by AcronymAllergy

"indigent" care (free), or at the university clinic (significantly-discounted price that was paid out-of-pocket).

These last two I have also seen, but would they apply to a private practice? Salaried clinical faculty generally see these, and grumble about them because they don't get as much billing credit that goes towards how big of a raise that they receive. But usually university/hospital policy requires some amount of this work.

It really depends on your market. I see people that are pretty much all out of pocket for therapy. However, we specialize in something that really is not available in the area, so people are willing to pay. The other issue with some insurance is that I offer a discounted rate and many people have insurance with high co-pays or no available providers in a 20 mile area, so it makes it worth it. I also have a few people with no insurance that just need to pay cash.

Originally Posted by Pragma

My understanding is that these can be terrible reimbursements as well...but I am sure it varies...

I know I saw some of the reimbursements, but I don't remember exact numbers. I think it was something along the lines of maybe $600-800 for the eval and report. My professor mostly conducted them just for the learning opportunity to us (his students).

Originally Posted by Pragma

I hear this is where the money is...

The first time I heard my advisor's purported ("purported" because they came from former students, not from my advisor directly) hourly, phone, and records review rates, I almost fell out of my chair. Suffice to say the money is good, but the work is obviously stressful (which I'm sure you know), the system is highly adversarial, and it's almost mandatory to have the lawyer pay ahead of time for services (my advisor completed at least one or two weeks'-long cases for which they still haven't been paid).

Originally Posted by Pragma

These last two I have also seen, but would they apply to a private practice? Salaried clinical faculty generally see these, and grumble about them because they don't get as much billing credit that goes towards how big of a raise that they receive. But usually university/hospital policy requires some amount of this work.

These were completed in the context of city indigent care hospitals. The on-site supervisor was salaried and loved having the cases available for us trainees (who were all funded via training grants), so he encouraged physicians to refer as many (appropriate) cases as they could. My advisor was actually very good about sending at least a few such cases our way each year that were done either as "professional courtesy" or for individuals in need as well (advisor was well known in the area both for professional accomplishments and the fact that he did these types of cases, so he would receive referrals from local clinicians who had clients that they felt would significantly benefit).

Besides the fact that I just have little desire to see patients everyday (especially only assessments), one of the biggest reasons I turned down a PP opp in neuropsych was that it was almost 100% insurance based. I was assured that the money could be really good (100k but no benefits)....if I completed 6 FULL evals per week. So, beyond the crazy 60 hour weeks, I didn’t see much of a future there. No upward trending/advancement, AT ALL. Reimbursement for clinical npsych exams from insurance companies will continue to dwindle over the next 10-20 years. I have no doubt. I would think practices that use this model will have to change things significantly over the next 10 years?

Originally Posted by AcronymAllergy

I know I saw some of the reimbursements, but I don't remember exact numbers. I think it was something along the lines of maybe $600-800 for the eval and report. My professor mostly conducted them just for the learning opportunity to us (his students).

Yeah depending on how much time they take - my postdoc supervisor routinely charged between 2-3K for a full neuropsych eval. I hear some places charge more.

Originally Posted by AcronymAllergy

The first time I heard my advisor's purported ("purported" because they came from former students, not from my advisor directly) hourly, phone, and records review rates, I almost fell out of my chair. Suffice to say the money is good, but the work is obviously stressful (which I'm sure you know), the system is highly adversarial, and it's almost mandatory to have the lawyer pay ahead of time for services (my advisor completed at least one or two weeks'-long cases for which they still haven't been paid).

There are some heavy-hitters in my city for forensic neuro work. I don't know if this is for sure, but I have heard of charges close to $30K for a forensic eval.

I also know some people who don't actually see the forensic patient, but act as "reviewers" so to speak of the data and case information. Not sure how much they got in total but their hourly rate was substantial.

For me, it's all too big of a headache. If I do some part time PP work I'll probably not get the best rate, but it also will only be supplemental income.

Originally Posted by erg923

Besides the fact that I just have little desire to see patients everyday (especially only assessments), one of the biggest several reasons I turned down a PP opp in neuropsych was that it was almost 100% insurance based. I was assured that the money could be really good (100k but no benefits)....if I completed 6 FULL evals per week. So, beyond the crazy 60 hour weeks, I didn’t see much of a future there. No upward trending/advancement, AT ALL. Reimbursement for clinical npsych exams from insurance companies will continue to dwindle over the next 10-20 years. I have no doubt. I would think practices that use this model will have to change things significantly over the next 10 years?

Sounds heavy, but not much more than postdoc. Until I got an efficient system going, I would imagine I'd need more than 60 hours per week though at that pace (initially).

I applaud you for not going the full clinical route - it wasn't appealing to me either.

Originally Posted by Pragma

Sounds heavy, but not much more than postdoc.

I think I am lazier than you,

Plus, I am about to be a father, so having my evenings free is gonna be important to me for about...the next 18 years.

Originally Posted by Pragma

Yeah depending on how much time they take - my postdoc supervisor routinely charged between 2-3K for a full neuropsych eval. I hear some places charge more.

Yep, those were the standard rates I heard for full-on neuropsych evals as well. For $800 or so, though, I'd imagine the expectations would've been somewhat lower (e.g., 2-4 hour battery rather than 6-8). One of the reasons they liked my advisor, I'd imagine, is because we still conducted a full battery despite the reduced compensation. He was fine with breaking even in some areas for no other reason than to further our training.

Originally Posted by Pragma

There are some heavy-hitters in my city for forensic neuro work. I don't know if this is for sure, but I have heard of charges close to $30K for a forensice eval.

Wouldn't surprise me, nope, That might be for either a particularly thorough, high-profile case, or a class-action-type arrangement, though. But even for a "simpler" forensic case, $5-10k for a more standard evaluation and deposition probably wouldn't be unheard of.

Originally Posted by Pragma

I also know some people who don't actually see the forensic patient, but act as "reviewers" so to speak of the data and case information. Not sure how much they got in total but their hourly rate was substantial.

Yeah, one of my advisor's former students has formed a large part of their clinical practice (as far as I know) from IMEs. The pay is good, but the time investment, and amount of reading and attention to detail required, are huge.

Originally Posted by edieb

one state in the Northeast is very close to passing RxP but is taking a stealth mode approach akin to what was taken in Louisiana. Just because you don't see much activity occurring in regards to RxP, doesn't mean there isn't activity.

you have seriously piqued my interest. All I can imagine is New Jersey since they had some chatter about this not too long ago and almost nothing popped up on the interwebs.

Originally Posted by erg923

Besides the fact that I just have little desire to see patients everyday (especially only assessments), one of the biggest reasons I turned down a PP opp in neuropsych was that it was almost 100% insurance based. I was assured that the money could be really good (100k but no benefits)....if I completed 6 FULL evals per week.

That is nuts. $100k for 6 (full to decent sized) batteries a week is a great model for them, but not you. The breakdown is about $350/assessment based on doing 6 x 48 wks. If you do 5x 38 wk it is $415/assessment. There are also issues with taking a cut gross or net payment, if there is a psych tech being used, the amount of time doing record review, etc.

Originally Posted by Pragma

Yeah depending on how much time they take - my postdoc supervisor routinely charged between 2-3K for a full neuropsych eval. I hear some places charge more.

The $'s seem all over the range, depends on the setting it seems. Forensic is its own fiefdom, and I would consider that path very different than 95% of other assessment work because of the extra hoops and risk associated with taking those cases. Excluding forensic work, I've seen $1k-$4.5k. The higher end would represent a senior level clinician (boarded and/or very experienced), and most that I have talked to about billing have not accepted insurance because taking insurance really knocks it down. Doing a 90801 + 5-6hr cap testing + feedback (if they even pay for it)...will not lead to a road of riches. Even an 8hr cap, which prob. assumes the feedback session and report writing already...still won't be great.

Originally Posted by Therapist4Chnge

That is nuts. $100k for 6 (full to decent sized) batteries a week is a great model for them, but not you. The breakdown is about $350/assessment based on doing 6 x 48 wks. If you do 5x 38 wk it is $415/assessment. There are also issues with taking a cut gross or net payment, if there is a psych tech being used, the amount of time doing record review, etc.

Well, I may have stretched it. I think 5 evals/week was getting most of their associates 100K. You always have the no show risk, of course. I am admittedly do not know how "full" there evals were/are. Its not a 6 hour testing battery...but at least several, I'm sure. Maybe one of the five were little bed soide things, probably...since they have a contract to serve some inpatient facilities. But still, point taken. Lots of productivity for a payout that didn’t seem quite commiserate with said productivity.

Originally Posted by Therapist4Chnge

The $'s seem all over the range, depends on the setting it seems. Forensic is its own fiefdom, and I would consider that path very different than 95% of other assessment work because of the extra hoops and risk associated with taking those cases. Excluding forensic work, I've seen $1k-$4.5k. The higher end would represent a senior level clinician (boarded and/or very experienced), and most that I have talked to about billing have not accepted insurance because taking insurance really knocks it down. Doing a 90801 + 5-6hr cap testing + feedback (if they even pay for it)...will not lead to a road of riches. Even an 8hr cap, which prob. assumes the feedback session and report writing already...still won't be great.

Yeah I think it comes down to how efficient folks are with their time and their reports. I was trained testing for 8 hours, but it just doesn't seem viable anymore unless you have techs doing it.

At a government training site I was at, we were limited to 3-4 hours of testing per day, but I basically was able to do it all (including write the report) in one day. Seemed very efficient, atlhough there were certainly some cases where additional testing would have been helpful. At my postdoc, testing was longer and reports were longer/more descriptive. It didn't seem like a viable model to replicate either, and the folks there were pretty stuck in their ways.

It is just not a battle worth fighting to me for my full time job, and I think a part of the decline in rates is because of abuse of the system by inadequately trained folks doing "neuropsychological" testing.

A solo neuropsych PP practice seems like it would be the tenth layer of hell based on what I have read on the npsych listerve about denials, coding issues, and time spent arguing/writing letters to insurers. Not to mention that is seems to change CONSTANTLY! And no tech?! I would go nuts doing 4 hours (or more) worth of testing 4-5 days/week.

Originally Posted by erg923

A solo PP neuropsych practice seems like it would be the tenth layer of hell from I read on the npsych listerve about denials, coding, and time spent arguing/writing letters to insurers. Not to mention that is seems to change CONSTANTLY! Not too mention no tech. I would go nuts doing 4 hours (or more) worth of testing 4-5 days/week.

Which is exactly why I would be happy to give up a percentage for them to take care of referrals and billing, and if it is part time supplementary income. I'd rather not depend on the coonstantly changing landscape to survive.