IOP supervised/run by internist?

[nexus73]

Can non psychiatrists be the supervising physician overseeing IOP programs? Specifically not an internist with addiction medicine training, just 3 year IM residency and over seeing CD and/or mental health IOP. Could there be issues with insurance fraud or other problems?

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[Sushirolls]

Only if the insurance company states some where how service X must be delivered by person Y.
Probably only a few insurance insurance companies have this listed in the contract.
I think I've seen some contracts reflect ECT had to be by a Psychiatrist.

But I suspect they either match up our Taxonomy code with Dx code clusters being billed - if they actually care.

Or if they are a company that has "mental health" "behavioral health" specific/separate contracts from more routine general medical contracts, then they already have a set list of CPT codes they'll let through. For instance, I've had UDS codes get carved out and paid for by general medical benefits with a company I was in network with, but they denied the claim for usual 99205 etc, because they had carved out their psych codes to be sent to some other random company...

So, this a bureaucracy layered sandwich, topped with yes, no, and a spread of maybe.

Other atypical example: I used to have a Sleep Medicine doctor sublease from me. I encouraged this person who was doing CBTi to also bill for 90833. No issues on a few insurance submissions. But this person also did Psych as base specialty, and could counter back to the insurance companies about 90833 use as they were also Psych if issues arose. But ultimately if insurance wants to steam roll over us and not pay... they will.

 

[mistafab]

I’m not sure what would be the issue. It’s essentially like having a pcp covering an IOP. Especially if the meat of the programming is just therapy / group therapy and structured activities, why not a pcp supervising?

Why would insurance care? I guess it matters more what population the IOP is targeting.

 

[nexus73]

I’m not sure what would be the issue. It’s essentially like having a pcp covering an IOP. Especially if the meat of the programming is just therapy / group therapy and structured activities, why not a pcp supervising?

Why would insurance care? I guess it matters more what population the IOP is targeting.

I guess the problem is that an internist isn’t a specialist in mental health, psychotherapy, or addictions (though some may be the latter). What supervision could they provide to social workers doing therapy? The social workers know more than them.

If insurance is paying for therapy great, but if paying for IOP I think this assumes the supervising doc is a mental health specialist.

This seems akin to an internist supervising nurse midwives, it's completely out of scope

 

[Merovinge]

I’m not sure what would be the issue. It’s essentially like having a pcp covering an IOP. Especially if the meat of the programming is just therapy / group therapy and structured activities, why not a pcp supervising?

Why would insurance care? I guess it matters more what population the IOP is targeting.

Why would an FM/IM/PCP be involved with a mental health IOP, that doesn't make any sense. This is 100% a mental health treatment center that is specifically designed for the field of psychiatry. IM in particularly gets virtually no training in psychiatry. Yes PCPs can do surgery and procedures legally, but we also have specialists for a reason.

 

[comp1]

What does overseeing mean? Do they own it financially? There's no specific problem in ownership exactly. I seriously doubt many psychiatrists are supervising the psychotherapy provided by social workers directly. These are LIPs. They don't need clinical supervision, theoretically. If there are psychiatrists or PMHNPs who work for the internist, this could be doable. If the literal only medical provider of any sort affiliated with the IOP is an internist without any additional training, that might be an issue.

 

[Merovinge]

What does overseeing mean? Do they own it financially? There's no specific problem in ownership exactly. I seriously doubt many psychiatrists are supervising the psychotherapy provided by social workers directly. These are LIPs. They don't need clinical supervision, theoretically. If there are psychiatrists or PMHNPs who work for the internist, this could be doable. If the literal only medical provider of any sort affiliated with the IOP is an internist without any additional training, that might be an issue.

I regularly attend supervision with the therapists at my PHP/IOP. Absolutely every PHP/IOP should have some supervision process for the master levels therapists, although psychologists or senior therapists are generally doing this work, more collaboration does not hurt. Certainly there should be a weekly discussion during a rounding/staffing between the therapist and psychiatrist for every patient.

I suppose I could run a botox clinic, or a clinic specializing in cosmetic surgery. There isn't a specific problem per say with how our licenses work, but it just makes absolutely no sense to have an intensive mental health treatment facility run by a doctor who does not specialize in mental health. This is so bizzaro to me that any psychiatrist would support this. IOP is significantly more intensive than OP care, I am not even sure why we would have psychiatrists at all if mental health work should just be done by IM.

 

[Stagg737]

I regularly attend supervision with the therapists at my PHP/IOP. Absolutely every PHP/IOP should have some supervision process for the master levels therapists, although psychologists or senior therapists are generally doing this work, more collaboration does not hurt. Certainly there should be a weekly discussion during a rounding/staffing between the therapist and psychiatrist for every patient.

I suppose I could run a botox clinic, or a clinic specializing in cosmetic surgery. There isn't a specific problem per say with how our licenses work, but it just makes absolutely no sense to have an intensive mental health treatment facility run by a doctor who does not specialize in mental health. This is so bizzaro to me that any psychiatrist would support this. IOP is significantly more intensive than OP care, I am not even sure why we would have psychiatrists at all if mental health work should just be done by IM.

The question seems more of an "is this legal/possible?" question rather than a "should this be done?" question. I think almost everyone would agree that it would be better for programs like this to be run by MH professionals, but that's a very different topic from "is this allowed".

 

[whopper]

Legally anyone with a medical license, and meeting their locality's requirements can practice any medicine, just that only a fool would do something like be a psychiatrist and practice surgery.

Now all that said and done not being in the specialty, while not illegal, opens up the problems of if being sued or otherwise investigated the question will come up as to why the physician is practicing outside their usual scope of practice and it could get the person in trouble. Also insurance, as mentioned above, might not want to reimburse for a doc who's not practicing within the usual scope of practice. If the doc isn't going to get paid, that in and of itself will prevent the overwhelming majority from wanting to do it.

Years ago I remember the first Ketamine clinics for depression being operated by an anesthesiologist. While they're not psychiatrists, anesthesiology was the field that had the most experience at that time with that medication. Highly questionable, but these clinics did it.

As an aside, so much of what we do is highly controlled by reimbursement. E.g. if Medicare starts reimbursing something that wasn't the norm at that time it often times then becomes a new norm cause there's not reimbursement and people could argue that an established government entity reimburses for it from a legal vantage.

 

[Merovinge]

Legally anyone with a medical license, and meeting their locality's requirements can practice any medicine, just that only a fool would do something like be a psychiatrist and practice surgery.

Now all that said and done not being in the specialty, while not illegal, opens up the problems of if being sued or otherwise investigated the question will come up as to why the physician is practicing outside their usual scope of practice and it could get the person in trouble. Also insurance, as mentioned above, might not want to reimburse for a doc who's not practicing within the usual scope of practice. If the doc isn't going to get paid, that in and of itself will prevent the overwhelming majority from wanting to do it.

Years ago I remember the first Ketamine clinics for depression being operated by an anesthesiologist. While they're not psychiatrists, anesthesiology was the field that had the most experience at that time with that medication. Highly questionable, but these clinics did it.

As an aside, so much of what we do is highly controlled by reimbursement. E.g. if Medicare starts reimbursing something that wasn't the norm at that time it often times then becomes a new norm cause there's not reimbursement and people could argue that an established government entity reimburses for it from a legal vantage.

This is still commonplace around my area, they only accept cash so they are not burdened by any concerns around insurance or reimbursement. Pretty wild what some will claim it treats with zero training in mental health.

 

[allantois]

This is still commonplace around my area, they only accept cash so they are not burdened by any concerns around insurance or reimbursement. Pretty wild what some will claim it treats with zero training in mental health.

Treating drug addicts with more addictive drugs in my experience

 

[smalltownpsych]

Many of the treatment places I have seen have non-clinical people running them and hire lots of midlevel therapists who dont even see that as a problem. Mental health is the one area where everyone thinks they can do our job. Of course, when it gets tough and chronic with suicidality, self harm or psychosis, then they come running to us. One of the reasons I prefer working with more severe populations is that I don‘t have to deal with the amateurs.

 

[Merovinge]

Many of the treatment places I have seen have non-clinical people running them and hire lots of midlevel therapists who dont even see that as a problem. Mental health is the one area where everyone thinks they can do our job. Of course, when it gets tough and chronic with suicidality, self harm or psychosis, then they come running to us. One of the reasons I prefer working with more severe populations is that I don‘t have to deal with the amateurs.

I'm quite biased but I cannot imagine recommending a PHP/IOP or RTC that is not run by an MD or PhD/PsyD with considerable experience in the space. It is really tough work to help people actually and sustainably recover that should not be done by an MBA/hospital administrator.

 

[whopper]

It also begs the question, WTF is going on with this place that they have a non-specialist running the clinical?

 

[allantois]

It also begs the question, WTF is going on with this place that they have a non-specialist running the clinical?

$$$

 

[lol.psych]

I could see it making sense in certain niche areas, or in cases where the IOP is part of a larger medical system (like if the internist were CEO/CMO/etc and there were psychiatrists working more directly with pts).
Like, if a specific internist wanted to work with pts with chronic pain or medically complicated eating disorders or something, started an IOP for it, and hired psychiatrists and miscellaneous-therapists to do the actual work (while the internist mostly kept tabs on the physical side of things [and made bank, presumably]), I could see that not being sketchy. But it requires psychiatrists to be involved, (regardless of their position within the business structure/hierarchy).