Bad Bill Before Congress

[PsyDr]

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The bill is a wolf in sheep's clothing. Psychologists do not need physician oversight to provide 99% of services. The only thing that physician oversight is required for is admitting patients (even NPs and PAs can't admit patients), and partial hospital programs. Both of these should have physician involvement and oversight.

ETA: also if proponents of this didn't real want a backdoor to medicine they would request that the medicare laws be amended to including provisions for psychologists, not for psychologists to be defined as physicians.

I'll play.

The scope of practice is defined on the state level. It is therefore confusing as to how one would think that CMS is capable of expanding scope of practice. CMS uses the term "physician" in an atypical manner that has little to do with scope of practice. This term refers to a provider who can independently bill CMS for their service, without a referral or consultation. Professions included in CMS's definition of "physician" are: MDs, DOs, DPMs, ODs, DCs, and DDS/DMDs. One would notice that MBBSes are NOT physicians under CMS rules. Neither are interns or residents, generally.

The a/b mac (b) enrollment agreement for psychologists requires consultation with/referral from a "physician" in order to get paid by CMS. Statement indicating that physician oversight is an unnecessary aspect of psychologists's CMS practice cannot be reconciled with CMS legal requirements to the contrary.

If one chooses to ignoring direct legal requirements to the contrary, and somehow assuming that CMS could change state laws about practice, one would still have to reconcile the fact that the AMA makes the CPT definitions, including who can bill for a CPT code. It is therefore unclear as to how any one could believe that CMS definitional changes would allow psychologists to use CPT codes, when the AMA is literally responsible for the rules of who gets to use a reimbursement code.

I am unsure as to how to reconcile statements indicating that changes in CMS's definitions has anything to do with admitting privileges, with state laws that allow psychologists to admit patients for emergency evaluation in: AK, CA, CT, DC, FL, HI, KS, MA, MD, MS, NV, NC, ND, OH, and TN. Likewise, it is unclear as to how one would reconcile state laws from several of the aforementioned states that allow NPs to admit patients for emergency evaluation.

I would be extraordinarily happy to have evidence to the contrary in any of those matters.

 

[deleted343839]

I'm curious whether there is a precedent for CMS reimbursement changes portending state-level scope of practice changes. I would think it would work in the other direction, but I'm willing to be enlightened.

Within psychology, RxP and the CMS definition have always been separate advocacy issues with somewhat different constituencies. The latter has a very long reach, as old as CMS itself. The second and final time psychology had a clear, tenable opportunity to be included in the CMS physician definition was during the era of late-1980s Medicare reform. Back then, third party reimbursement for psychological services was still reasonable, and the American Psychological Association of that era was not a health policy-savvy entity. In the 1990s, the leadership of the American Psychological Association began to realize how they blew it. They eventually got a consolation prize in the form of some new, poorly reimbursed CPT codes that I doubt most on this forum are familiar with.

Anyway, that's the context for the CMS definition legislation. It is naive and bumbling, but more about getting reimbursement for what we already do than expanding scope of practice (as PsyDr mentioned, that's a state issue anyway).

Now... has anyone validated that VA legislation rumor?

 

[WisNeuro]

In some cases these psychologists are pretty smart folk who worked very hard for their PhD. Sure it was in research design and not very likely to be clinically relevant research, but they then see 24 year old joe smoe who took night nursing classes into night NP school, knows nothing about mental health but works as a FPNP "specializing" in mental health.

Just appoint of clarification. Almost every clinical psych PhD from a reputable program is doing clinical research.

 

[PsyDr]

@MamaPhD

NO. Completely separate issues. Remember that the AMA is the one who makes the CPT codes. CPT codes include definitions of who can provide that service.

One will note that CMS definitional changes happen AFTER scope of practice changes, OR have no relationship to scope of practice issues whatsoever.

Example:
In 2014, Missouri created a license for medical school graduates who never completed a residency. This license is called "assistant physicians" (NOT PAs). The state law specifically addressed CMS definitions, rather than allowing CMS to decide.

 

[Stagg737]

The scope of practice is defined on the state level. It is therefore confusing as to how one would think that CMS is capable of expanding scope of practice. CMS uses the term "physician" in an atypical manner that has little to do with scope of practice. This term refers to a provider who can independently bill CMS for their service, without a referral or consultation. Professions included in CMS's definition of "physician" are: MDs, DOs, DPMs, ODs, DCs, and DDS/DMDs. One would notice that MBBSes are NOT physicians under CMS rules. Neither are interns or residents, generally.

Within the VA system pharmacists and NPs can bill independently for MH patients on their panel or evaluations of those who walk into the clinic without referral, so either this is an incomplete section of the law or multiple VAs are breaking federal laws.

I am unsure as to how to reconcile statements indicating that changes in CMS's definitions has anything to do with admitting privileges, with state laws that allow psychologists to admit patients for emergency evaluation in: AK, CA, CT, DC, FL, HI, KS, MA, MD, MS, NV, NC, ND, OH, and TN.

This is inaccurate, or at the very least missing a huge caveat, for at least one of those states.

Example:
In 2014, Missouri created a license for medical school graduates who never completed a residency. This license is called "assistant physicians" (NOT PAs). The state law specifically addressed CMS definitions, rather than allowing CMS to decide.

And those graduates cannot bill or be employed without the supervision of a physician, may only work in geographical areas that meet federal definitions of "underserved", have significant restrictions on prescribing controlled substances, and can ONLY work in primary care (so no MH anyway). I'm not sure how this relates to what is being discussed, but seems to be skirting the very significant restrictions that were placed when this bill was enacted.

 

[Taddy Mason]

This is inaccurate, or at the very least missing a huge caveat, for at least one of those states.

Can confirm that this not accurate for 3 of the states listed. Psychologists can file for emergency evaluation (i.e., brought to the ED by police against the patient’s will for evaluation) but NOT admission.

 

[wolfvgang22]

Got this email from the APA today:

Earlier this month, APA asked you, our advocates, to assist us in raising alarm over proposed legislation that would allow psychologists to prescribe and manage medication in the Veteran's Affairs Health Care System under a congressionally-proposed pilot program. And you responded! In the past two weeks over 1,100 psychiatrists sent a total of 3,600 letters to Capitol Hill reaching nearly every member of Congress!

As a combined result of your efforts, the work of APA staff, and partnership with our colleagues at the American Medical Association, we are pleased to report that the U.S. House of Representatives Veterans Affairs Committee removed the problematic provision and passed a clean underlying suicide prevention bill that the full House passed this week.

APA wants to thank you for your important role in this effort!

 

[comp1]

Yeah, it's still explicitly limited to scope of practice within the state.

 

[PsyDr]

Within the VA system pharmacists and NPs can bill independently for MH patients on their panel or evaluations of those who walk into the clinic without referral, so either this is an incomplete section of the law or multiple VAs are breaking federal laws.



This is inaccurate, or at the very least missing a huge caveat, for at least one of those states.



And those graduates cannot bill or be employed without the supervision of a physician, may only work in geographical areas that meet federal definitions of "underserved", have significant restrictions on prescribing controlled substances, and can ONLY work in primary care (so no MH anyway). I'm not sure how this relates to what is being discussed, but seems to be skirting the very significant restrictions that were placed when this bill was enacted.

1) I'm glad you brought that up. Since federal law ( 1862. A. 3) specifically prohibits the VA from billing Medicare, I'm having a hard time understanding your question . If you're referring to the VA's billing Medicare, you should absolutely report that to the authorities. If you're referring to contractual agreements between the VA and private insurance companies, CMS rules don't apply at all.

However, I suspect that you have purposely introduced that topic as a means of tying OP's citation of HR884 into the VA topic. If so, this is the most erudite transition that I have read on SDN. OP brings up a bill about revising 1861, which doesn't seem to be related to the VA. You bring up 1862 of the same law, which explains how this area of the law is related to the VA.

2) Splik stated that physician oversight was unnecessary except for admitting. This is not true. In my rush, I conflated state laws that allow for detention for emergency evaluation with state laws that allow admission. This was an error, I apologize. My point that CMS rules have nothing to do with state laws (including admitting privileges), stands. My point that CMS rules require physician oversight of psychologists, stands.

3) You're proving my point. So the bill cited was HB884. That bill is about how CMS labels providers in their internal system. Posters opined that changes in CMS labels could change psychologists scope of practice. Since scope of practice is defined by state law and since CMS does not have the power to change scope, it would seem that these fears are misplaced. I offered MO334.036 as an example of how state law dictates things, and how applying the CMS label has nothing to do with scope of practice.

I agree with your description of how the state law (MO 334.036) clearly defines the scope of practice for assistant physicians. I might go a bit further than you and point out that this law dictates that these providers must identify themselves as "assistant physicians", and are allowed to use the title "Dr.".

Section 2 (a) of MO334.036 dictates how the federal agency, CMS, should label this class of provider in CMS' internal system. Specifically, "An assistant physician shall be considered a physician assistant for purposes of regulations of the Centers for Medicare and Medicaid Services (CMS) ". I think this is a pretty great example that disproves the concerns that changes in CMS titles will have any affect on scope of practice.

 

[wolfvgang22]

1) I'm glad you brought that up. Since federal law ( 1862. A. 3) specifically prohibits the VA from billing Medicare, I'm having a hard time understanding your question . If you're referring to the VA's billing Medicare, you should absolutely report that to the authorities. If you're referring to contractual agreements between the VA and private insurance companies, CMS rules don't apply at all.

However, I suspect that you have purposely introduced that topic as a means of tying OP's citation of HR884 into the VA topic. If so, this is the most erudite transition that I have read on SDN. OP brings up a bill about revising 1861, which doesn't seem to be related to the VA. You bring up 1862 of the same law, which explains how this area of the law is related to the VA.

2) Splik stated that physician oversight was unnecessary except for admitting. This is not true. In my rush, I conflated state laws that allow for detention for emergency evaluation with state laws that allow admission. This was an error, I apologize. My point that CMS rules have nothing to do with state laws (including admitting privileges), stands. My point that CMS rules require physician oversight of psychologists, stands.

3) You're proving my point. So the bill cited was HB884. That bill is about how CMS labels providers in their internal system. Posters opined that changes in CMS labels could change psychologists scope of practice. Since scope of practice is defined by state law and since CMS does not have the power to change scope, it would seem that these fears are misplaced. I offered MO334.036 as an example of how state law dictates things, and how applying the CMS label has nothing to do with scope of practice.

I agree with your description of how the state law (MO 334.036) clearly defines the scope of practice for assistant physicians. I might go a bit further than you and point out that this law dictates that these providers must identify themselves as "assistant physicians", and are allowed to use the title "Dr.".

Section 2 (a) of MO334.036 dictates how the federal agency, CMS, should label this class of provider in CMS' internal system. Specifically, "An assistant physician shall be considered a physician assistant for purposes of regulations of the Centers for Medicare and Medicaid Services (CMS) ". I think this is a pretty great example that disproves the concerns that changes in CMS titles will have any affect on scope of practice.

Well, the APA was pretty darn concerned. You should ask them to explain it to you if you are really interested.

 

[WisNeuro]

Well, the APA was pretty darn concerned. You should ask them to explain it to you if you are really interested.

They are fair questions, you were the one who posted the link for action. Did you advocate for signing on to an issue not having any idea what the issue actually is?

 

[wolfvgang22]

They are fair questions, you were the one who posted the link for action. Did you advocate for signing on to an issue not having any idea what the issue actually is?

Look, the bill has been changed and passed already this week. It's not an issue anymore right now. If you don't like it you can write your legislators. I'm done arguing with psychologists about it.

 

[scoopdaboop]

Why do people work for the VA. They're always trying to screw actual physicians.

 

[FatherPsychiatry]

Got this email from the APA today:

Earlier this month, APA asked you, our advocates, to assist us in raising alarm over proposed legislation that would allow psychologists to prescribe and manage medication in the Veteran's Affairs Health Care System under a congressionally-proposed pilot program. And you responded! In the past two weeks over 1,100 psychiatrists sent a total of 3,600 letters to Capitol Hill reaching nearly every member of Congress!

As a combined result of your efforts, the work of APA staff, and partnership with our colleagues at the American Medical Association, we are pleased to report that the U.S. House of Representatives Veterans Affairs Committee removed the problematic provision and passed a clean underlying suicide prevention bill that the full House passed this week.

APA wants to thank you for your important role in this effort!

Great news. Hopefully other systems follow suit in some way.

 

[WisNeuro]

Look, the bill has been changed and passed already this week. It's not an issue anymore right now. If you don't like it you can write your legislators. I'm done arguing with psychologists about it.

Well, according to the actual wording of the bill, it was never an issue to begin with, at least not anywhere close to what was stated. I'd be a little wary of my advocacy organization if they had to outright lie to get me to contact my legislators.

 

[wolfvgang22]

Why do people work for the VA. They're always trying to screw actual physicians.

I think it's more Congress is trying to take care of veterans on an insufficient budget and are often looking for cheaper ways to get the job done. I don't think it's anything specifically intended to screwing physicians alone. Veterans get screwed, too. The U.S. produces tons of veterans, promises them healthcare, and then Congress fails to fund it to the same degree they fund weapons and wars. Just my opinion.

 

[AbnormalPsych]

Look, the bill has been changed and passed already this week. It's not an issue anymore right now. If you don't like it you can write your legislators. I'm done arguing with psychologists about it.

LOL.