Cases needed for two APA initiatives

 Cases needed for two APA initiatives

#1 – MPS members can have a national impact on discriminatory reimbursement practices. The U.S. Department of Labor and Maryland Attorney General Brian Frosh are both interested in pursuing investigation of insurance carriers who are violating the federal parity law by paying lower rates to psychiatrists than they pay to other physicians for the same CPT codes. The most common codes used by both psychiatrists and other physicians are New Office Visits (99201-99205), Established Office Visits (99211-99215), Inpatient Admissions (99221-99223), Inpatient Follow-ups (99231-99233), and Discharges (99238-99239). If a carrier has patterns of discrimination where they routinely pay less for these codes when psychiatric services are delivered, then action may be taken against the violators.

The APA requests documentation of psychiatrists’ reimbursement, as well as patient EOBs for both their psychiatric and their medical services.  Please find a document (or create one) that includes the payer and what they paid you or your patient for your services. Be sure to black out the patient identifiers. Also, ask a few patients to fax copies of both their psych and their medical EOBs (explanation of benefits), blacking out identifiers, if possible; they will be removed by APA if needed. These cases will allow APA to compare E&M codes paid for psych services with those paid for medical services.

#2 – MPS members can also help document allegations of improper prior authorization procedures.  Extreme prior authorization situations have been shared with the APA; however specific information is needed to understand who to complain to, and to strategize how best to deal with these issues.  When you send documentation, please include:

  1. Name of patient’s insurance company
  2. Source of the insurance for the patient (Medicare, exchange plan, employer plan and if so, name of employer if you know it)
  3. Name of the pharmacy benefit company
  4. Drug requiring pre certification
  5. Time spent trying to get the prior authorization
  6. Any impact on the patient while waiting.

If you prefer, you can also submit your experience with prior authorizations for prescriptions to theMPS Prior Authorization Data Collection Instrument created by Steve Daviss, M.D.

Send documentation by fax to  703-907-1089 (this goes directly to APA General Counsel Colleen Coyle’s office).  Note: Colleen confirmed that sending this payment information to APA is okay as it is for documenting improper or unlawful evidence, not for comparing rates for anti-competitive reasons.  If you’d like to submit information, but have questions, contact either Kery Hummel or Steve Daviss.