As many of you are aware, a special waiver for providers of mental health services to Medicare recipients has been in effect since the beginning of the COVID Public Health Emergency.  This temporary waiver has allowed Medicare recipients to receive services from psychologists via telehealth with no in-person visit required.  This is an exception to the standard Medicare rule which has an in-person visit requirement for telehealth service recipients.  Our Medicare advocacy team at APA has been hoping that the temporary waiver of this requirement would be renewed beginning October 1.  However, due to present demands on Congress at this time, this extension did not occur before the September 30 deadline.  We continue to hope for a renewal of the temporary waiver at some point in the future.  

In the meantime, I believe it will be helpful for providers of Medicare services to be aware of the following key requirements which will take effect October 1, 2025.  Remember, these requirements could be waived through an act of Congress at some point in the future.  

• Individuals who have been receiving ongoing telehealth services must have an in-person visit within 12 months of the period beginning October 1, 2025. Exceptions to this rule are possible for existing clients who have been receiving services.  According to the Center for Medicare and Medicaid Services: “Specifically, if the patient and practitioner agree that the benefits of an in-person, non-telehealth service within 12 months of the mental health telehealth service are outweighed by risks and burdens associated with an in-person service, and the basis for that decision is documented in the patient’s medical record, the in-person visit requirement will not apply for that particular 12-month period. For example, situations in which the risks and burdens associated with an in-person service may outweigh the benefit could include, but are not limited to, instances when an in-person service is likely to cause disruption in service delivery or has the potential to worsen the patient’s condition(s). The risks and burdens associated with an in-person service could also outweigh the benefit if a patient is in partial or full remission and only requires a maintenance level of care. Other examples of such instances may include the clinician’s professional judgment that the patient is clinically stable and/or that an in-person visit has the risk of worsening the patient’s condition, creating undue hardship on self or family, or if it is determined that the patient is at risk for disengagement with care that has been effective in managing the illness. Practitioners must also document that the patient has the ability to obtain any needed point of care testing, including vital sign monitoring and laboratory studies. Practitioners must note the exception for any applicable 12-month interval.”

• New clients must experience an in-person visit within the previous 6 months before the start of telehealth services. No exceptions to requirement are permitted.

Unfortunately, this continues to be a changing and confusing circumstance.  I will continue to make any new developments on this topic available to OPA members as they emerge.

Jim Broyles, Ph.D.
Ohio Psychological Association
Director of Professional Affairs
395 East Broad Street, Suite 310 | Columbus, Ohio 43215
P. 614.266.1301
jbroyles@ohpsych.org

Shortly after the public health emergency was declared, access to virtual mental health services was expanded by changing several of these older policies.  Medicare recipients may now receive tele-mental health services directly in their homes and other locations with fewer restrictions.  Unfortunately, some of these newer policies are only temporary.  At this point, unless changes are made, Medicare recipients will be required to have at least one in-person visit with their mental health provider every six months beginning January 1, 2025.  As many of us are aware, this change will make accessing mental health care impossible for some Medicare beneficiaries due to a variety of significant barriers this will impose.  In addition. behavioral health services provided for physical health diagnoses, billed using the Health Behavior Assessment and Intervention Codes, will also be ineligible for delivery via telehealth after the current year.  Unfortunately, changing these policies literally takes an act of Congress, and since commercial insurance tends to follow Medicare, most mental health policy advocates agree that making a permanent change in this policy is highly relevant for all mental health providers, even those who don’t participate in Medicare.

The Telemental Health Care Access Act (H.R. 3432/S. 3651) has been introduced to Congress to address this issue.  The bill would make the changes identified above permanent.  In an effort to advocate for this bill, APA facilitated my travel to Washington D.C. on May 23 to participate in a panel discussion intended to shed light on this issue.  This presentation was made directly to interested members of Congress and their staff and afforded them the opportunity to ask questions which enabled them to more clearly understand the issues involved with the legislation.  

Following this, I returned to D.C. on June 9-11 to participate in APA’s Grassroots Fly In advocacy event.  This is an important event sponsored by APA for each SPTA’s Federal Advocacy Coordinator.  Unfortunately, Ohio’s FAC, Dr. Scott Sperling, was unable to attend this year and I attended in his place.  This event enabled participant psychologists to meet with key members of Congress or their staff to lobby for legislation highly relevant for the practice of our profession.  The pictures below illustrate meetings I attended, accompanied by APA’s Dr. Stephen Gillaspy (thank you Stephen!) to discuss the importance of Telemental Heathcare Access Act, as well as other key bills in front of our representatives right now: the Increasing Mental Health Options Act (S. 669/H.R. 8458) and the Complete Care Act (H.R. 5819/S. 1378).  The first of these would allow psychologists working in facilities to provide services independently, without the approval of a physician, and the second would enable CMS to provide technical assistance and support to help primary care practices adopt an integrated care model.  Psychologists play key roles in practices using these models.  As you can see here, I was able to me with staff members in the offices of Sen J.D. Vance, Sen Sherrod Brown, Rep. Joyce Beatty, and Rep. Jim Jordan.  I believe, as a result of our conversations, I was able to shed light on important issues facing Ohio psychologists relevant to their work.  

I welcome your feedback!

Jim Broyles, Ph.D.
Director of Professional Affairs
Ohio Psychological Association
email Jim

Unfortunately for the majority of our practices which utilize electronic billing, some of our claims may be held by the clearinghouses until a safe electronic pathway is established to allow our claims to reach the right destination.  Many practices are likely to experience delays in claim reimbursements or even the possibility that billed claims may be lost.  Requests for preauthorized services may be similarly delayed.  It is unclear how significant or widespread the delays may be or when Change may become fully operational again.  We are being discouraged from submitting duplicate claims.  Doing so may produce even further delays.  Claims may still be submitted to the insurance payers directly.

Change Healthcare has stated they have a high degree of certainty that other systems beyond their own are not at risk currently, and that they will be certain of the safety of the larger environment before they return online.  As of this writing, they have been able to reestablish their prescribing service, which is the first progress reported by them since the event began last week.  I think we can see this as a glimmer of hope.

I am monitoring the circumstance and will be reporting to you as I know more or have any solid recommendations for you.  Feel free to email me.

NOTE: The Company recognizes, but does not require, modifier GT (via interactive audio and video telecommunications systems) for reporting telemedicine services.”

Optum
Telehealth coverage for psychological services will continue.  Telehealth Place of Service Codes (02 or 10) should be used.  Audio only (modifier FQ) or audio and video (modifier 95) connections are permitted.  Medicare Advantage plans will also follow these guidelines.  The pre-pandemic requirement to attest to telehealth training has been dropped.

I will keep updated on any further information from these companies I become aware of.  As always, please feel free to reach out with questions.

Jim Broyles, Ph.D.
Director of Professional Affairs
Ohio Psychological Association
jbroyles@ohpsych.org

Ohio Board of Psychology 
The rules governing the delivery of psychological services via telehealth did not change with the onset of the COVID crisis and the advent of the Public Health Emergency (PHE).   Therefore, no changes are expected from our board regarding practice via telehealth with the end of the PHE.  More information from our board regarding the practice of telehealth can be found at their website:

https://psychology.ohio.gov/laws-rules-resources/advisories-resources/telepsychology-resources

Several OPA members have expressed concerns about information they hear from members of other professions.  For example, some medical professionals may be required to limit or eliminate certain services via telehealth.  Concerned psychologists should be aware that these professions are governed by separate boards who maintain an entirely separate set of rules regarding their practice.  As psychologists, we follow the rules of our own Ohio Board of Psychology.  

HIPAA Rules
Psychologists who practice via telehealth should be mindful of the impact of the end of the PHE on HIPAA rules.  At the onset of the PHE, the federal government relaxed restrictions on the type of platforms permitted for use via telehealth.  Specifically, the US Department of Health and Human Services stated:

During the COVID-19 national emergency, which also constitutes a nationwide public health emergency, covered health care providers subject to the HIPAA Rules may seek to communicate with patients, and provide telehealth services, through remote communications technologies.  Some of these technologies, and the manner in which they are used by HIPAA covered health care providers, may not fully comply with the requirements of the HIPAA Rules.

OCR will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency.  This notification is effective immediately. 

Essentially, this states that with the end of the PHE, the requirement that all telehealth platforms used to deliver services be HIPAA compliant will be enforced.  While at this point it is highly likely that most psychologists have been able to secure HIPAA compliant platforms for use when delivering psychological services, this serves as a a good reminder to check their compliance in this area.  

Medicare
Many Medicare providers are aware that Medicare relaxed certain standards to make telehealth services more accessible to Medicare recipients.  These include changes such as the removal of location restrictions and allowing audio only psychotherapy sessions.  These new polices were implemented on a temporary basis initially.  Subsequently, some of these changes were made permanent, while others were extended beyond the end of the public health emergency.

Changes which were made permanent:

• Medicare patients can receive telehealth services for behavioral/mental healthcare in their home. (An initial face to face visit is required). 
  
• There are no geographic restrictions for originating site for behavioral/mental telehealth services.
  
• Behavioral/mental telehealth services can be delivered using audio-only communication platforms.
  
• Rural hospital emergency department are accepted as an originating site.
  

Temporary changes which will extend through the end of 2024:

• Medicare patients can receive telehealth services authorized in the Calendar Year 2023 Medicare Physician Fee Schedule in their home.
  
• There are no geographic restrictions for originating site for non-behavioral/mental telehealth services.
  
• Some non-behavioral/mental telehealth services can be delivered using audio-only communication platforms.
  
• An in-person visit within six months of an initial behavioral/mental telehealth service, and annually thereafter, is not required.
  

Typically, Medicare telehealth services are reimbursed at a lower rate than face-to-face services. The Medicare temporary PHE changes included revising this so that telehealth service reimbursement was equal to face-to-face services.  This will also continue through the end of 2024.  However, the possibility still exists that the lower telehealth rate will be reinstated at the end of this time period.  Our APA representatives continue advocate for a change in this policy.  (If you are not a member of APA, please join.

Once the PHE ends, psychologists should begin billing telehealth using the new POS Codes (10 for clients receiving services at home, 02 for everything else).  Psychologists interested in being a Medicare telehealth provider should also be mindful of the fact that Medicare requires providers to use an actual physical address (not a PO Box) for their office location.

Ohio Medicaid
At the start of the PHE, the Ohio Department of Medicaid also created temporary telehealth policies to make telehealth more accessible to Ohio Medicaid recipients.  Later in 2020, a new set of telehealth rules was made permanent.  Therefore, the end of the PHE will have no impact on the way telehealth works with Medicaid.  A more detailed behavioral health provider manual is available on the Ohio Department of Medicaid website.


Commercial Insurance Companies
Changes from commercial insurance companies tend to be the most unpredictable.  Throughout the pandemic, much like Medicare and Medicaid, many of these companies created temporary policies to make telehealth more accessible to their insureds.  These policies tended to be revised as the PHE progressed, and the changes were often announced just before the expiration of the previous policy.  This makes upcoming changes with these companies the most difficult to predict.  Having said this, I will add the following ideas which may be reassuring for OPA members.

• Many coverage policies from commercial insurance tend to follow Medicare, so the above Medicare developments may influence their decisions.
  
• The law in the State of Ohio currently requires commercial companies to offer some form of telehealth coverage.
  
• Most commercial insurance companies were covering some form of telehealth before the pandemic, so it is highly unlikely more extensive telehealth coverage will be discontinued.  More likely is the reinstatement of former restrictions, such as requiring provider to attest to having received some form of telehealth training, or discontinuing coverage for audio only services.  I will continue to update OPA members as significant changes emerge.

Please feel to contact me directly with questions.

Jim Broyles, Ph.D.
OPA Director of Professional Affairs

A key effort from this coalition to help attain our object has been to conduct regular surveys of our respective memberships. We ask providers about challenges they experience in interacting with insurance organizations and synthesize the results in a report. This report is distributed to key leaders in our healthcare world, including most major private insurance companies, Medicaid managed care organizations, the Ohio Department of Insurance, and the Ohio Department of Medicaid. Our goal is to make sure our voices are being heard, and we are making efforts to look for ways to strengthen our ongoing dialogue with these entities. 

Psychologists have done an amazing job of responding to these surveys, and account for a large percentage of the total survey respondents. I thought it may be helpful to share with you results from our more recent survey, which was completed in the spring of this past year. 

The responses are summarized in three themes: 1) A small portion of claims require remedy but take up disproportionate time. 48.5% of you report that claims processing adds a significant administrative burden to your practice. 2) Administrative burden may be driving more providers to stop accepting insurance. 30.8% of you report your practice is seriously considering a move away from acceptance of third-party payment. 3) Claims denials have an outsized influence on clinical practice and can disrupt care. 33.3% of you report denial of psychological testing deemed essential by the treating clinician. 72.2% of you report denial or discouragement of psychotherapy session length. These themes illustrate that providers are struggling to provide accessible, high-quality services with such a high administrative burden and that many are choosing to stop taking insurance at all. 

Based on data we have gathered, we are in the process of making these important recommendations:

Guidance and transparency on medical necessity 
Our coalition would like every third-party payment company to provide a definition of medical necessity that is accessible to all paneled providers and consumers. Supplemental guidance providing evidence and reasoning for denial based on session-length, diagnosis, medication or intervention would support providers in maintaining high quality standards and reduce administrative burden. 

Innovation in claims remedying systems 
Our coalition welcomes any and all innovation that reduces the time and effort required to remedy errors and move claims along. An ideal system would allow for true continuity when communicating so that providers do not have to repeat information and would include email and phone communication options. 

Increased use of centralized credentialing resources 
While this most recent survey focused on claims, credentialing is a constant topic among our members. Centralization systems like CAQH feel redundant when providers are having to repeat this information with each individual company.

As always, I appreciate OPA members for your support of this work, and I encourage you to reach out to me with questions or suggestions.

Jim Broyles, PhD
OPA Director of Professional Affairs

• If they answer yes to both questions, you do not need to give the patient a GFE at this time. (Later in 2022 or in 2023, when HHS develops regulations for patients who intend to use their insurance, APA will provide guidance for sending GFE information to that insurer.)
• Regarding question B, it is APA’s interpretation that who submits a claim to the patient’s insurance (patient or psychologist) is not critical. Nor does it matter whether you are in or out of network with the patient. What is important is that the patient intends to use their insurance to cover your services.

Recently I have received questions regarding how to provide a GFE when the cost of services can be quite uncertain for many clients at the outset of treatment, particularly when the GFE is required before the client is initially evaluated.  The Practice Update FAQ document and its accompanying GFE template address this issue.  Here is an excerpt:

Q1: What are some strategies for structuring GFEs to address competing concerns and future uncertainty?

Because psychotherapy is a reoccurring service, you can provide a GFE covering up to a year of services. How you structure your GFE involves a tension between:

• advising patients about the potential high end of fees, which reduces the risk of your actual billing exceeding your GFE; and
  
• giving patients a more realistic view of costs if treatment goes well and there are not complications.

APA advocacy staff have assured me they fully recognize the undue burden this law and its accompanying requirements place on psychologists, and they intend to advocate with CMS regarding this.  Clearly, implications of these requirements can be vague, confusing, and extremely difficult to us to implement.  APA is joining forces with other professions to make our concerns heard.  I will do my best to keep you updated on developments as they occur.

Finally, remember there is no penalty at this point for being out of compliance with the law.  While this may be only a grace period for the current year, this fact will likely ease anxiety about how to proceed in this confusion.  Should a client feel their GFE was not given in compliance with the law, at worst they may request a dispute resolution.  
 
I will continue to update as I know more.

Many OPA members have asked about the “No Surprise Act” which will go into effect January 1, 2022.  The law was finalized at the beginning of October, and our APA legal resources have been working to understand the implications of this law for practicing psychologists.  Their advice for us is summarized here.  We need to pay close attention to the following ideas.  They are discussed in more detail in the attached article. 

• The law applies to any licensed provider providing any healthcare service (including psychologists). 
  
• For the time being, the most important procedural changes apply to any clinician providing services to self-pay and uninsured clients. 
  
• The most important action for clinicians to take when providing services to these clients is a “good faith estimate” at the outset of treatment or evaluation.  Suggested forms to use are attached.  Specific time frames for providing the estimate are spelled out in the article. 
  
• Insurance companies will also be required to provide their version of the “good faith estimate” for those clients who want to use their insurance, and providers will be involved in that process.  However, the current deadline for implementing this portion of the law is April 2022.  The various insurance entities will take the lead on informing us how we will need to be involved in this process. 
  

The Center for Medicare and Medicaid Services recently issued their policy updates on how Medicare will be delivered and reimbursed for psychologists and other clinicians during 2022.  I remind everyone these developments are quite significant for us since many other private insurance companies follow CMS policy.  Also, these developments are in many cases the direct result of American Psychological Association advocacy work on our behalf as well efforts made by many of you who were able to make your voices heard through the recent email campaign.  Here is an article which gives more detail about these changes.  Please pay close attention to the following: 

• The Medicare reimbursement rate cut signed into law 12/10 will delay the rate cut described in the article. 
  
• Many of the changes in policy will take place after the end of the currently declared Public Health Emergency (PHE).  The end of the PHE is nowhere in sight currently due to the continuing negative impact of COVID nationally. 
  
• At the end of the PHE, Medicare recipients may continue to receive many services via audio only telehealth connection. 
  
• Once the PHE ends, audio-only telehealth services for mental health and substance use disorder (SUD) services will require an in-person visit within six months of the initial telehealth visit and within 12 months of any subsequent telehealth visit. Exceptions to this are identified in the article.  CMS has not yet clarified how this rule impacts Medicare recipients who are receiving ongoing telehealth services when the PHE ends. 
  
• Psychological and neuropsychological testing will remain temporarily available telehealth services.  They are approved through the end of 2023. 
  
• New codes to allow for “therapeutic monitoring” are in development.” 

New Place of Service codes for telehealth are also in development for Medicare and are not yet required but will be implement at a later time.  This is not mentioned in the article, and I will be updating members on this at a later point. 

As always, feel free to email me with questions. 

These codes are developed by AMA drawing on input from the American Psychological Association (APA). For this reason, APA provides us with essential information about code definition and rules. Below are links to three resource documents provided by APA.

• Frequently asked questions about the 2013 psychotherapy codes
  
• Psychotherapy Codes for Psychologists
  
• The 2013 Psychotherapy Codes: An Overview for Psychologists

In regards to the recent listserv posts, here is a quote from APA’s FAQ document. 

Do I consider time spent doing additional work outside of face-to-face time with my patients when deciding which psychotherapy code to use? 

No, the time spent arranging for services, providing reports and communicating with other health care professionals is not included in the length of the psychotherapy session. Such activity is considered part of the post-service work already built into the psychotherapy codes. This is not something new for 2013, as these activities were considered post-service work under the psychotherapy codes in effect for 2012. 

More detailed descriptions of pre- and post-service work for the 2013 psychotherapy codes 90832, 90834 and 90837 appear below. 
 
Pre-service work: Prepare to see patient and/or family member. Review record. Communicate with other professionals and significant others such as guardians, caretakers and family members. 
 
Post-service work: Arrange for further services. Coordinate care in writing or by telephone with patient, family and other professionals such as a primary care provider. Document intra-service and post-service work activities. Provide written or telephone reports to third-party payers. 

I urge everyone to closely examine the sources they use for professional guidance very carefully. Sometimes communication can be vague and therefore misinterpreted, but I have no doubt that sources of very misleading guidance are out there. I am OPA’s main resource for insurance help. My help is available to any psychologist who is a member. Please feel free to reach out. 

The first development is a new rule issued by the Department of Health and Human Services which prohibits “information blocking.”  The rule went into effect April 5 of this year, and its intention is to allow the free flow of electronic health information.  The rule applies to all psychologists who use electronic health record systems (not paper records).  This rule could require, depending on the circumstance, a psychologist’s clients to have instant access to their records.  One of the circumstances which would exempt a practicing psychologist from allowing this instant access would be if they operate with an electronic health record system which does not have the client instant access capability.  This would apply to most EHR systems currently used by private practice psychologists.  These systems may be updated at some point in the future, so it is a good idea for OPA members to check with their EHR vendors about their plans in this area.  More detailed information regarding this development may be obtained from APA here:

• New federal rule affects psychologists with electronic health records (apaservices.org)
• Detailed FAQs about the information blocking rule (apaservices.org)

The second development is a federal law which was passed at the end of last year known as the “No Surprise Law.”  It will go into effect at the beginning of 2022.  Some discussion about this law occurred at a recent meeting of OPA’s Insurance Committee.  Similar discussion occurred on our DPA listserv.  A main concern has been imitations the law places on out of network charges allowed.  No doubt we will be receiving a more careful analysis and practical implementation suggestions from APA as we move closer to the effective date.  In the meantime, here are some initial ideas on the implications of this law.  

The “No Surprise Law” applies to those patients who receive services from in-network facilities.  Since most private practice psychologists do not provide services in this type of setting, they would be exempt from the law.  Psychologists may also help protect any out of network fees they charge through their informed consent procedure: educate clients about the fees charged, the client’s responsibilities for these fees, and options for obtaining similar services from an in-network provider at a potentially lower cost.  These ideas could be incorporated into the informed consent forms already in use in our practices.  I will be sure to continue providing updates in this area as new developments occur.  As always, feel free to email me with questions. 

• Most major insurers were providing coverage for telehealth services before the pandemic and are highly likely to continue covering these services in some form once the pandemic crisis has ended. 

• Many major insurance entities, including Medicare and the Ohio Department of Medicaid, created emergency policies to make access to telehealth services more accessible. These included many exceptions, such as allowing the provision of audio only services, waiving coinsurance requirements, and removing restrictions on the use of telehealth platforms. Most of these policies, since they were temporary, included expiration dates. Many psychologists have mistakenly interpreted these expiration dates as the date coverage for telehealth will end.

• Some insurance companies have created emergency policies with specific expiration dates. In many cases, as this date has approached, the company has extended the date into the future. This has occurred on multiple occasions for most of these companies. Any expiration date given below should be interpreted cautiously with this in mind.

• Most insurance companies have little influence over the “self-funded” or ERISA plans they are associated with. While most have made an effort to encourage the employers responsible for these plans to cover telehealth, some have not complied. Those have may not continue to do so. It is very wise for psychologists to check client benefits before providing telehealth services.

• A bill presently in the Ohio Legislature (HB 679) presently requires insurance companies to offer coverage for telehealth for psychologists. Contact your state representative to support this bill. 

Anthem’s emergency policy remains the same and will stay in effect at this point until 9/30/21

“Effective from March 19, 2020, through July 31, 2021, Anthem’s affiliated health plans will cover telephonic-only visits with in-network providers. Out-of-network coverage will be provided where required by law. This includes covered visits for mental health or substance use disorders and medical services, for our fully-insured employer plans, individual plans and Medicaid plans, where permissible. From March 19, 2020, through September 30, 2021, Anthem will cover and waive cost shares for telephonic-only visits with in-network providers for our Medicare Advantage plans. Cost shares will be waived for in-network providers only. We encourage our self-funded customers to participate, and these plans will have an opportunity to opt in.”

Aetna is giving no definite ending date to their policy

“Aetna’s liberalized coverage of Commercial telemedicine services, as described in its telemedicine policy, will continue until further notice.
 
“All member cost-sharing waivers for covered in-network telemedicine visits for outpatient behavioral and mental health counseling services for Commercial plans are active until January 31, 2021. Aetna self-insured plan sponsors offer this waiver at their discretion.”

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Medical Mutual: 

Medical Mutual was covering telehealth before the pandemic. During the pandemic they created the following exception to their more permanent policy. No ending date for this exception as been set.

“Individual (telehealth) therapy can be conducted by a provider to their patients. At this time, Medical Mutual is waiving the requirement that an initial behavioral health visit be done in person before visits can be conducted via telehealth (telemedicine). Also at this time, Medical Mutual is waiving the requirement that telehealth (telemedicine) visits have a visual encounter. Therefore, telephonic visits with an audio-only connection will be covered.”

Cigna:

“During this time of heightened awareness of the novel Coronavirus, COVID-19, and its classification by the World Health Organization (WHO) as a global pandemic, we want to keep you up to date on how Cigna Behavioral Health is working to help support you and your patients with Cigna coverage.

“Many behavioral providers have contacted us about delivering telehealth sessions. While we have been reimbursing for telehealth since 2017, and will continue to do so post-pandemic, we have made some temporary revisions to telehealth requirements to support continuity of care during this unique situation. The following changes are effective through July 20, 2021, unless otherwise noted.

“Please note:

• As federal guidelines continue to evolve in support of the COVID-19 pandemic, we proactively extended applicable customer cost-share waivers and other enhanced benefits, through February 15, 2021 for treatment and through July 20, 2021 for testing and testing-related services, unless otherwise mandated by the state. This guidance is subject to change.
• Cigna Behavioral Health will continue to reimburse for telehealth after July 20, 2021, unless otherwise noted.”

Optum:

Optum states they will continue their temporary policy which includes audio (telephone only) coverage and waiving the requirement for attestation and use of their telehealth platform through June 30. They encourage those interested to arrange to be permanent telehealth provider:

“For the past several years, virtual visits (telemental health) for certain outpatient services have been covered under certain behavioral health plans or Employee Assistance Programs (EAP) offered to members. After the COVID-19 emergency period ends, Optum will continue to allow members to receive certain covered services via the telehealth modality. If you would like to continue to provide telemental health services to our members and permanently participate in our virtual visits network, please visit the virtual visits page on Provider Express. There, you will find information about virtual visits and you can complete an attestation to participate in our virtual visits network. If you are already a virtual visits provider or have already completed an attestation, no further action is required.

“If you have any questions about Optum’s standard virtual visits program, please contact our Provider Service Line at 1-877-614-0484, or contact your Provider Relations Advocate.”

Humana:

Continues to offer coverage for telehealth with emergency policies in place. This includes audio only and cost share waivers. The policy will be in effect through the end of the national Public Health Emergency. However, they note this policy may be terminated by them at any time without notice.

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Medicare :

Adaptation to Medicare’s telehealth policy will continue throughout the national Public Health Emergency. APA and others are currently lobbying congress to make these changes permanent. Please look for your opportunity to support these efforts.

Ohio Medicaid:

Shortly after the onset of the pandemic last year, the Ohio Department of Medicaid created emergency rules for telehealth to make virtual services more accessible to providers and our clients. These new rules were meant to be temporary, and their expiration was set to coincide with end with the state level public health emergency. On November 15, 2020, a new set of permanent rules regarding telehealth was implemented by ODI which replaced the temporary rules. These may be found here: https://codes.ohio.gov/ohio-administrative-code/rule-5160-1-18

OPA is currently maintaining an information hub, which can be found by clicking here.

APA also is currently maintaining an information hub, which can be found by clicking here.

Many members seem now to have a better understanding of current issues with delivering and billing teletherapy services during the current crisis. I encourage everyone to look back at my previous updates if you still have questions about this. I am now receiving questions regarding current emergency policies many insurance entities now have in place. Misconceptions and confusion exist regarding when these policies will expire and what may be allowed by the various insurance entities once these emergency policies are no longer in effect. In my last update, I stated most insurance companies were already covering telehealth (teletherapy) before the current circumstance. The emergency, temporary policies implemented by most pertain to relaxing restrictions for telehealth delivery which were part of their standard, ongoing policies. These included requirements such as making attestations directly with the company, requiring the use of company's web-based telehealth platforms, requiring therapy sessions to use visual as well as auditory connections, etc. Once the recently issued emergency policies expire, it is highly likely the company or entity will revert to their previous policy, which for most allowed teletherapy within the parameters of those former restrictions. For some of these former restrictions, our current circumstance likely prohibits their active implementation. For example, some companies required the use of the company’s special web-based platform. It is quite unlikely these platforms have the capacity to meet the current demand brought about by the crisis. Therefore, the current demand would need to be reduced considerably before this older requirement could be put back in place. 

Most of the new, emergency policies were identified as having specific expiration dates. I identify these dates for each entity I am aware of below. In some cases, the expiration is set to coincide with the current state of emergency declared for the State of Ohio by the Governor or nationally by the President. A state of emergency has been declared on both levels with no official expiration in sight. Other entities, mostly private companies, give expiration dates as a part of the policy. However, these dates issued by private companies have already been revised more than once. As I monitor the developments from most of these companies, I find them to be actively responding to the crisis circumstances as they unfold, revising their policies to adapt to the need and demand as it evolves. Among other things, this means that for those companies who have emergency policy expiration dates rapidly approaching, I believe it is highly likely they will revise the date. (In the case of Optum, for example, this has happened twice already). 

These are the current emergency policy expiration dates I am aware of as of today, May 19, 2020:

• Anthem—June 19
  
• Cigna-- May 31
  
• Medical Mutual— the policy will be in effect “during the current state of emergency in Ohio.”
  
• Aetna-- August 4
  
• Medicare—" . . . through the end of the [national] emergency declaration.”
• Optum—“This change in policy is effective until May 31, 2020, but we may extend that date as necessary and will communicate through all appropriate channels.”
  
• Medicaid— ” . . . for the duration of the state of emergency [in Ohio].
  

I will continue to report updated information as I become aware of it.

This is a continuation of my messages to you regarding the ongoing changes occurring on the insurance/healthcare regulation world in response to the COVID-19 crisis.  My previous updates which can be found by clicking here. 

OPA is currently maintaining an information hub, which can be found by clicking here.

APA also is currently maintaining an information hub, which can be found by clicking here.

I was recently asked a question regarding the sweeping emergency adaptations taking place with insurance company policies and regulations.  Specifically, the member asked whether it was likely the insurance companies would continue to cover teletherapy sessions after April 30, which is a question I'm sure many of you have.  This was my response:

"Most insurance companies were already covering telehealth (teletherapy).  The emergency, temporary policies implemented by most pertain to relaxing restrictions for telehealth which were part of their standard, ongoing policies.  These included requirements such as making attestations directly with the company, requiring the company's web based telehealth platforms, requiring therapy sessions to be visual as well as auditory connections, etc.  Most of the new, emergency policies were identified as having specific expiration dates.  I am more typically seeing these policies set to expire somewhere late May or mid June.  The soonest, Optum, is set to expire April 30.  However, theirs was one of the earliest issued, and the policy specifically states " . . . but we may extend that date as necessary and will communicate through all appropriate channels."  In general, most of these companies appear to be monitoring and responding to circumstances as they are rapidly developing."

OPA is currently maintaining an information hub, which can be found by clicking here.

APA also is currently maintaining an information hub, which can be found by clicking here.

A member recently asked for more information on which companies are promising to waive copays and deductibles for relevant telehealth treatment during this crisis time.  I will include all information I have received thus far on this topic here.  I also understand that the information I am giving in my updates will sometimes be contradicted by the telephone representatives from the respective insurance companies.  I ask you to bear in mind most of my information comes from medical directors, network managers, and official bulletins from the companies.  It may be that telephone representatives from the companies have not been updated.

Medical Mutual

Medical mutual recently released an FAQ document updating their policy, which includes the following information: 

“During the current state of emergency in Ohio, Medical Mutual is waiving the requirement that telehealth (telemedicine) visits have a visual encounter. Therefore, telephonic visits, in addition to web or app, will be covered at this time.”

“During the current state of emergency in Ohio, Medical Mutual is waiving the requirement that an initial behavioral health visit be done in person before visits can be conducted via telehealth (telemedicine).”

“Individual therapy can be conducted by a provider to their patients. During the current state of emergency in Ohio, Medical Mutual is waiving the requirement that an initial behavioral health visit be done in person before visits can be conducted via telehealth (telemedicine). At this time, we are also waiving the requirement that telehealth (telemedicine) visits have a visual encounter. Therefore, telephonic visits, in addition to web or app, will be covered.”

No information regarding waiving of copays or deductibles for behavioral health is available.

Cigna

Please refer to previous updates.  Teletherapy is permitted, no attestation is currently being required, and telephone only sessions are permitted.  I have received no information on waiving copays or deductibles.  The following coding guidelines should be used:

• Appropriate Current Procedural Technology® (CPT®) code in Field 24-D for the service(s) provided
  
• Modifier 95** in Field 24-D to specify telehealth (see sample claim form below)
  
• Place of Service 02 in Field 24-B (see sample claim form below)

Anthem

Please refer to previous postings regarding this company.  They are still in effect.  In addition, Anthem gives the following guidance:

Effective March 17, 2020, Anthem’s affiliated health plans will waive member cost share for telehealth (video + audio) visits, including visits for behavioral health, for our fully-insured employer plans, individual plans, Medicare plans and Medicaid plans where permissible for 90 days. Cost sharing will be waived for members using Anthem’s telemedicine service, LiveHealth Online, as well as care received from other providers delivering virtual care through internet video + audio services. Self-insured plan sponsors may opt out of this program.

Effective March 19, 2020, Anthem will cover telephone-only medical and behavioral health services from in-network providers and out-of-network providers when required by state law for 90 days. Anthem will waive associated cost shares for in-network providers only except where a broader waiver is required by law. Exceptions include chiropractic services, physical, occupational, and speech therapies. These services require face-to-face interaction and therefore are not appropriate for telephone-only consultations. Self-insured plan sponsors may opt out of this program.

Optum

Starting March 31, 2020 until June 18, 2020, United Behavioral Health (dba Optum Behavioral Health) will waive cost-sharing for in-network, outpatient, behavioral health telehealth visits for members of Medicare Advantage, Medicaid and fullyinsured Individual and Group market UnitedHealthcare (UHC) health plans. We will work with all health plans and self-funded customers who want us to implement a similar approach. Providers are encouraged to confirm member benefits and coverage provided by their health plan at the time of service due to the rapidly changing situation. This updated policy applies to members of Medicare Advantage, Medicaid and Individual and Group market health plans issued by UnitedHealthcare. Providers that treat members of Medicare Advantage, Medicaid and fully-insured Individual and Group market health plans issued by UnitedHealthcare and administered by Optum Behavioral Health do not have to collect co-pays from fully insured UHC plan members effective March 31, 2020 through June 18, 2020. Again, please confirm the member’s benefits at the time of service due to the rapidly changing situation. Out-of-Network member benefits and cost-sharing will apply, as applicable, according to plan terms. Check out the latest telehealth policy updates for behavioral health services, reimbursement and coding guidelines and member cost sharing updates and resources at our new COVID-19 Provider Hub on Provider Express here.

Billing guidelines: Optum Behavioral Health will reimburse telehealth services which use standard CPT codes and a GT modifier or a Place of Service of 02 for both video-enabled virtual visits and telephonic sessions to indicate the visit was conducted remotely.

Medicare

All previously posted guidance still applies, with this update I just received from APA.  This is new blling guidance for Medicare only:

The Centers for Medicare and Medicaid Services (CMS) has once again issued new guidance on the delivery of health care services during the COVID-19 public health emergency. Effective March 31, 2020 providers furnishing services through telehealth should use the place of service that would have been reported if the service was being furnished in-person. CMS is making this change to identify when it is appropriate to pay a non-facility fee, rather than a facility fee which would have automatically been included under POS 02. 

To illustrate, a psychologist who would have seen patients in a private office should use POS 11. Those who would have treated the patient in a clinic or skilled nursing facility should use the appropriate POS. All claims for telehealth services should now include modifier 95.

While phone only psychotherapy continues to be prohibited by Medicare (a real concern for many of us), phone-only billing codes are available for more limited interventions.  More information on this can be found here:
https://www.apaservices.org/practice/clinic/covid-19-audio-only-phone-service-codes

BWC (updated provide by Dr. David Schwartz, OPA Chair BWC Task Force)

As previously posted by OPA’s BWC lead, Dr. David Schwartz

1. They will allow telephone-only sessions as psychotherapy (which has to be pre-authorized as per their normal rules0 but will not pay it at psychotherapy rates. They want us to use phone consultation codes which pay MUCH less). Obviously this isn’t good and any strategies to encourage them would help- my thought is that if Medicare gets on board that would be a strong comeback.
2. They have dropped the ‘no smartphone” rule and will allow their use in teletherapy.
3. They don’t see a need to develop telemedicine IMEs, feeling they have enough evaluators willing to do face to face. I personally think that is a bad idea and contrary to best practices in terms of minimizing exposure. Not sure how hard to come back on that one -a big concern is that too many of their evals are done by a small group of folks who make that their primary practice and do a poor job- they were on our radar before the sudden appearance of all these alligators.

A more general crisis resource page can be found here: https://ohpsych.org/page/PandemicResources

The Ohio Governor has issued a stay at home for Ohio residents.  Individuals are still permitted to leave their homes to visit health care professionals.  Our work as mental health and substance use providers is considered an essential activity and is permitted to continue to operate.

I am seeing many questions and requests regarding HIPAA compliant technology for communication with clients who are homebound.  In a previous update, I reported the Department of Health and Human Services website states right now it “will waive potential penalties for HIPAA violations against health care providers that serve patients through everyday communications technologies during the COVID-19 nationwide public health emergency.”   The best advice we are receiving from APA in on interpreting this statement is 1) make a good faith effort to secure a HIPAA compliant means of communication and 2) if none is available connect with your client via other available means.  I believe at this point the best direction we are being given is to make the well being of our clients be our highest priority.

While some definitions of teletherapy include audio only means of interacting with clients, many insurance company regulations have typically required the connection to be both visual and audio.  Due to the circumstance of so many individuals having more sophisticated electronic communications unavailable to them and being reachable only by phone, many insurance companies have been adapting their regulations, allowing audio only (cell/telephone) connections to conduct therapy.  In past updates I have documented companies who have made these revisions in their regulations and am including more here.

MEDICAID

The Ohio Department of Medicaid recently passed temporary, emergency rules. (It will also be made available on OPA’s resource webpage).  The rules make allowance for the audio only connection as well give specific definitions for the patient site and practitioner site.

CIGNA

Cigna has also issued a recent revision of their policy:

As a general requirement, Cigna-participating outpatient providers must complete an attestation to deliver telehealth sessions. During this interim period, however, telehealth attestations are not required. Please note that regardless of your attestation status, it is expected that you use a secure platform to deliver services and follow all Health Insurance Portability and Accountability Act (HIPAA) requirements.

While telephonic sessions are not typically covered in accordance with our Medical Necessity Criteria, we are making an exception during this interim period. You may provide telephonic sessions to patients who do not have access to technology to participate in telehealth sessions, as appropriate.

MEDICARE

As of this posting I have received no update on changes to Medicare beyond those in my 3.20.20 update.  Many of you have expressed concern regarding Medicare recipients who reachable only by phone.  I have heard that many of you have reached to your current members of Congress to advocate for a change with this issue.  My hope is that this proves effective.

EMERGENCY LICENSURE

 Many of asked about reaching client who are quarantined in other states.  Clearly, only psychologists who are licensed to practice in other states are permitted to provide psychological services there.  At this point, many states have created emergency orders and procedures for allowing temporary licensure in those states.  ASPPB is doing a good job of tracking those states who have made such provisions, and that information may be obtained here: https://www.asppb.net/page/covid19

The Ohio Board of Psychology also has created similar emergency rules and procedures for psychologists licensed in other states.  They may be found here:
https://psychology.ohio.gov/Applicants/Nonresident-Temporary-Permission-to-Practice

I will continue these updates as information becomes available to me.

A more general crisis resource page can be found here: https://ohpsych.org/page/PandemicResources

The Ohio Governor has issued a stay at home for Ohio residents.  Individuals are still permitted to leave their homes to visit health care professionals.  Our work as mental health and substance use providers is considered an essential activity and is permitted to continue to operate.

I am seeing many questions and requests regarding HIPAA compliant technology for communication with clients who are homebound.  In a previous update, I reported the Department of Health and Human Services website states right now it “will waive potential penalties for HIPAA violations against health care providers that serve patients through everyday communications technologies during the COVID-19 nationwide public health emergency.”   The best advice we are receiving from APA in on interpreting this statement is 1) make a good faith effort to secure a HIPAA compliant means of communication and 2) if none is available connect with your client via other available means.  I believe at this point the best direction we are being given is to make the well being of our clients be our highest priority.

While some definitions of teletherapy include audio only means of interacting with clients, many insurance company regulations have typically required the connection to be both visual and audio.  Due to the circumstance of so many individuals having more sophisticated electronic communications unavailable to them and being reachable only by phone, many insurance companies have been adapting their regulations, allowing audio only (cell/telephone) connections to conduct therapy.  In past updates I have documented companies who have made these revisions in their regulations and am including more here.

MEDICAID

The Ohio Department of Medicaid recently passed temporary, emergency rules. (It will also be made available on OPA’s resource webpage).  The rules make allowance for the audio only connection as well give specific definitions for the patient site and practitioner site.

CIGNA

Cigna has also issued a recent revision of their policy:

As a general requirement, Cigna-participating outpatient providers must complete an attestation to deliver telehealth sessions. During this interim period, however, telehealth attestations are not required. Please note that regardless of your attestation status, it is expected that you use a secure platform to deliver services and follow all Health Insurance Portability and Accountability Act (HIPAA) requirements.

While telephonic sessions are not typically covered in accordance with our Medical Necessity Criteria, we are making an exception during this interim period. You may provide telephonic sessions to patients who do not have access to technology to participate in telehealth sessions, as appropriate.

MEDICARE

As of this posting I have received no update on changes to Medicare beyond those in my 3.20.20 update.  Many of you have expressed concern regarding Medicare recipients who reachable only by phone.  I have heard that many of you have reached to your current members of Congress to advocate for a change with this issue.  My hope is that this proves effective.

EMERGENCY LICENSURE

 Many of asked about reaching client who are quarantined in other states.  Clearly, only psychologists who are licensed to practice in other states are permitted to provide psychological services there.  At this point, many states have created emergency orders and procedures for allowing temporary licensure in those states.  ASPPB is doing a good job of tracking those states who have made such provisions, and that information may be obtained here: https://www.asppb.net/page/covid19

The Ohio Board of Psychology also has created similar emergency rules and procedures for psychologists licensed in other states.  They may be found here:
https://psychology.ohio.gov/Applicants/Nonresident-Temporary-Permission-to-Practice

I will continue these updates as information becomes available to me.

All past my past updates are located here:
https://ohpsych.org/blogpost/1567785/Director-of-Professional-Affairs-Blog

One of the most significant questions on everyone’s mind is the use if telephone (audio only) to conduct psychotherapy sessions.  As I mentioned previously, our regulations come from a variety of sources.  Some definitions of teletherapy may include audio only, but typically regulations from insurance entities do not.  In the last few days I have seen the insurance companies working quickly to revise many of their policies regarding teletherapy, and some are including telephone sessions in their definitions, at least temporarily.  My hope is that more insurance entities will follow suit in the coming days.

As I reported previously, Medicare has lifted some restrictions on teletherapy, allowing more recipients to receive services via teletherapy (see my last update).  However, they continue to require the connection used to be audio as well as video.  APA and NASW very recently sent a letter to CMS imploring them to relax this restriction to permit audio only.  Also, many are aware of the Medicare requirements for supervised services. CMS stipulates that for services billed to Medicare which are delivered using a supervisee, the supervisor must be physically present in the office suite for help if needed.  This requirement has not changed.  

I have been able to make contact directly with a Medical Mutual representative who was able to supply me with their policy.  They do cover teletherapy, and there are no other specific requirements other than the billing procedures (below).  Audio only sessions are not considered a part of their teletherapy definition.  

Anthem Blue Cross/Blue Shield recently issued this update, which permits audio only sessions.  From their FAQ document:
Anthem covers telehealth (i.e., video + audio) services for providers who have access to those platforms/capabilities today.

Effective March 17, 2020, Anthem’s affiliated health plans will waive member cost share for telehealth (video + audio) visits, including visits for mental health, for our fully insured employer plans, Individual plans, Medicare plans and Medicaid plans where permissible for 90 days. Cost sharing will be waived for members using Anthem’s telemedicine service, LiveHealth Online, as well as care received from other providers delivering virtual care through internet video + audio services. Self-insured plan sponsors may opt out of this program.
 
Will Anthem cover telephone only services in addition to telehealth via video + audio?
Anthem does not cover these services today (with limited state exceptions) but we are providing this coverage for 90 days effective March 19, 2020, to reflect the concerns we have heard from providers about the need to support continuity of care for Plan members during extended periods of social distancing. Anthem will cover telephone-only medical and behavioral health services from in-network providers and out-of-network providers when required by state law. Anthem will waive associated cost shares for in-network providers only except where a broader waiver is required by law.

Aetna continues to be difficult for me to contact.  Fortunately, the Directors of Professional Affairs throughout the country maintain a good network of interconnection.  My counterpart in Utah was able to forward information she received from her contact with the company.  I received the following:

Aetna – Aetna has waived the requirement for patients to use their preferred vendor, TelADoc. All contracted providers are eligible to provide virtual visits for Commercial Plan members for the next 90 days. Self-insured plans do have the option to opt-out of this program so we will still want to verify policies prior to rendering service. 

At one point, there was a question about their teletherapy provider requirement, which was restricted to one platform, TelaDoc.  It would appear at this point that restriction has been lifted, and all providers are being made eligible to provide teletherapy services.

As mentioned in my last updates, when billing teletherapy services, the procedure remains the same for all entities: the CPT Code continues to be the same as that used for face to face therapy.  However, the claim must report place of service as “02” and include the modifier “95” or “GT.” 

APA is offering some great teletherapy resources:

• Office and Technology Checklist for Telepsychology Services ... https://www.apa.org/practice/programs/dmhi/research-information/telepsychological-services-checklist
• A sample telepsychology informed consent form... https://www.apa.org/practice/programs/dmhi/research-information/informed-consent-checklist
• APA Telepsychology webinars... https://apa.content.online/catalog/product.xhtml?eid=15132&eid=1921

OPA resource page:
https://ohpsych.org/general/custom.asp?page=PandemicResources

I ask you to keep in mind the rules and restrictions which govern the delivery of our services come from multiple sources, including state law, federal law, and insurance company policy and regulation. Each of these can interact with one another in a complex way which adds to the confusion. This means that, as the circumstances evolve, few are completely clear on the full implications for our work.

At this point, as far as I know, all rules governing psychologists as telepsychology providers remain in place. We have received word (as many of you have heard) that Governor DeWine has issued an emergency order to “reduce restrictions on telehealth.” This could have implications for our board rules or might also have implications for insurance company restrictions. Dr. Ron Ross of the Ohio Board of Psychology and I have been in communication regarding this and unfortunately have been able to obtain very little information on the details of this order. (I’m sure they are very busy right now).

It would also appear that that federal entities have relaxed HIPAA restrictions during the crisis. The Health and Human Services website states it “will waive potential penalties for HIPAA violations against health care providers that serve patients through everyday communications technologies during the COVID-19 nationwide public health emergency.”  Presently the APA Department of Legal and Regulatory Affairs are at work on defining the implications of this for psychologists, and we hope to have an update tomorrow. This may mean that HIPAA compliant platforms are not necessary for connecting with your client during the crisis. 

In my last message I mentioned that Medicare enforces strict regulations on the delivery of teletherapy services, and that an emergency law was passed by Congress to allow the Secretary of Health and Human Services to relax these standards, and the change was awaiting his approval. That approval has been granted. According to the CMS website: “Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020.” 

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

Stay tuned for more guidance from APA on this also. 

Optum’s (UHC/UBH) website is now stating: “Telephonic Care: For members or providers who do not have access to HIPAA-approved technology required to conduct a video-enabled virtual session, we will now accept telephonic sessions.”  My hope is that other insurance companies may follow this lead, but no other has created a similar policy as far as I know. 

Cigna has confirmed that teletherapy is permitted for many of their plans, and an attestation is required. Click here to view a flier that I received from their medical director. Many members have verified that Medical Mutual is covering teletherapy session, but my efforts to contact them have received no response. (Again, I’m sure they are very busy).  As I receive more details from these companies, I will share with you. 

If any of you have more information to add, please email me directly and I will do my best to verify the information and keep you updated.

Jim Broyles, PhD
Director of Professional Affairs
Ohio Psychological Association
395 E. Broad St. Suite 310 | Columbus, Ohio  43215 | 614-266-1301

In response to the current, evolving pandemic situation, many of you have been asking about the use of telepsychology and related insurance regulations. Dr. Jim Broyles, OPA Director of Professional Affairs, has spent considerable time gathering information for you and will undoubtedly continue to do so over the course of the next several days and weeks. His intention is to give you as much information as is available at this time. He asks that you understand that additional and updated information is highly likely given the fact that circumstances are evolving very quickly. OPA and Dr. Broyles will work to provide updates on a regular basis.

TELEPSYCHOLOGY TRAINING

Please consider that offering psychotherapy via an electronic platform (telepsychology) is considered a specialty area by our Ohio Board of Psychology and should be undertaken by those psychologists who have completed the training requirements and are legally and ethically competent to deliver these services. We are aware of a very recent news story stating, “. . . Ohio Governor Mike DeWine announced he has filed emergency rules for complete mental health telehealth coverage.” We do not know the implication of this for these Board of Psychology requirements nor for insurance entities. Information on this will be one of the updates provided as it becomes available. For those interested in getting up to speed on telepsychology training, a number of training resources are available online. While it is very difficult here to be definitive regarding which sources of training suffice to make one competent in this area, our OPA telepsychology experts offer guidelines in what good training should cover. Click on the following links to access summary documents from APA and OPA.

Dr. Ron Ross of the Ohio Board of Psychology recently issued a statement regarding contact with clients which falls outside the parameters of treatment defined as telepsychology:

“[Ohio rules give] . . . license holders authority to use their judgment about when a client requires extra support between appointments without having to document all the processes in the telepsychology rules. Therefore, the rule authorizes inter-session telecommunications to manage crises even by license holders who do not necessarily “practice” telepsychology. With the evolving landscape of illness, social distancing, quarantines, and the risk of increased anxiety and other psychological symptoms, it is reasonable for license holders to interpret “ensuring client welfare” broadly, given our dramatic shift in context. Specifically, license holders may judge, on a case-by-case basis, that client welfare and continuity of care requires temporary, judicious use of telephone sessions when the client and license holder are prohibited from meeting in-person because of efforts to contain COVID-19. This temporary leeway is rooted in a specific context and is not to be used as a basis to undertake routine use of telecommunications by exemption from the telepsychology rules for reasons unrelated to the COVID-19 crisis. License holders who 2 wish to routinely deliver services via telecommunications must establish and maintain telepsychology competence and practice in accord with the telepsychology rules.”

MEDICARE AND MEDICAID

Until recently Medicare has maintained strict rules regarding the use of telepsychotherapy, including limiting service recipients to those individuals located in specific geographic regions as well as requiring that the client be present at their primary care physician’s office to receive the service. Last week, an emergency temporary bill was passed by Congress to lift those restrictions. This bill authorizes the present Secretary of Health and Human Services to lift those restrictions. As of this writing that has not occurred and there may be specific requirement accompanying that change, and OPA will update you as that information becomes available. Also, be aware that Medicare Advantage plans are authorized to provide services that the federal Medicare program does not. Clients who participate in these plans may well be eligible to receive tele-services. At this time, we have no information specific to these plans, but we suspect the allowances are congruent with the company’s non-Medicare plans.

Current rules governing Medicaid allow for “telehealth.” The rules may be found here: http://codes.ohio.gov/oac/5160-1-18v1. Psychotherapy is identified as a covered service within the parameters identified by the rules. Our contact with the Ohio Department of Medicaid has indicated that these rules are currently under revision and that a more definitive guide (which may include a lifting of certain restrictions) will be forthcoming soon. We will pass this along as soon as it is received. Similar to Medicare, Medicaid Managed Care Organizations have more latitude in terms of what they offer than the state program, and our contact with CareSource has assured us that telepsychology services are covered. Unfortunately, we have not received informaton from other Medicaid companies.

PRIVATE INSURANCE

Optum (UHC/UBH) has assured OPA that they encourage telehealth services and even offer an electronic platform for “virtual visits.” Participants in the delivery of these services are asked to sign an attestation. Their policy and directions for complying with requirements may be found here:

https://www.providerexpress.com/content/ope-provexpr/us/en/Important-upates.html

Anthem Blue Cross Blue Shield has stated that telehealth services are allowed with guidelines:

The Provider can utilize their own interface for Telehealth service and are not required to use Live Health Online or any other specific vendor

• The tool used to provide Telehealth must include both audio and visual connection capabilities, i.e. the physician and patient must both see and hear each other during the interaction.
• The Provider can bill using their current TINs/NPIs.
• There is a broad list of services available to be billed via Telehealth, and we follow the Medicare Learning Network (MLN) publication to determine those services.
• E-consults between physicians are NOT covered via the Telehealth policy. Only member to physician interactions are included.
• Claims must be billed using POS “02” for Telehealth and using modifiers “GQ”, “GT” or “95”. This requirement is consistent with Medicare. Not using this POS or modifiers will result in post-pay audits and recoveries.
• Telehealth services will reimburse at rates equivalent to our facility based professional rates (not office based).

The above mentioned MLN publication includes our most used psychotherapy codes.

We are hearing from some very good sources that Medical Mutual allows for telepsychotherapy as a service. We have yet to verify that or know about any specific parameters required by them. Dr. Broyles has a call in to them and will share information as it becomes available. Also, remember when billing telepsychology for any insurance entity, the basic billing procedure is the same: as stated above, the claim must report place of service as “02” and include the modifier “95” or “GT.” These trigger the insurance entity’s system to recognize your claim as being for the telepsychology service. Otherwise, the CPT Code and other information is the same as for face to face services.

Preesently, OPA has no other information about other companies, but we hope to get this soon. If any of you receive information to add to what has been presented here, please reach out to Dr. Jim Broyles directly, especially with a contact person if possible. Keep in mind Dr. Broyles' work with this issue and the information  gathered would not be possible without our staff at APA; an entire network of DPA’s across the country; Dr. Leslie McClure, Christine Taylor, and our other OPA Insurance Committee members, as well as, Dr. Mark Babula, one of OPA’s Telepsychology leads.

Presently, both federal and state parity laws exist which affect insurance companies providing health plans here in Ohio. Unfortunately, weaknesses exist in the current laws which allow the above difficulties to continue. The current bill (SB 254/HB 443) will establish new standards for those companies who provide health insurance here in Ohio, as well as effective means of measuring compliance with these standards. This bill, should it become law, will be one more step toward a more balanced health care system which recognizes and supports the delivery adequate behavioral healthcare services in our state. 

I often remind our members that the passage of such bills which do not favor our insurance companies can often be an uphill battle. A primary reason for this is the resources available to insurance companies to lobby against such legislation which have no counterpart in our professional association. That means that a bill such as this is far more dependent on grassroot support from individuals. My purpose in writing here is to help OPA members understand the potential impact of this legislation on their professional lives. The next step, however, will be up to individual professionals and Ohio citizens. At the right time, you will receive an Action Alert email from OPA with sample letters asking you to contact your legislature to support this piece of legislation. Please be on the lookout and willing to make our voice heard! 

In addition, click here for a billing and coding guide developed by APA which gives more detailed information about the codes and how they are to be used when billing for HBAI services.  This helpful document gives essential information, including:

• Description of services and factors which determine when they are considered medically necessary
  
• A list and description of the new codes
  
• Documentation and reporting guidelines
  
• Guidelines for correct use of the codes
  

Please feel free to contact me for questions or support. Unfortunately, many insurance companies may experience confusion during the initial implementation period about code definition or their correct usage. I encourage you to bring these issues to my attention, also. (jbroyles@ohpsych.org).  

A presentation on this topic will be offered at the 2020 OPA Convention on Friday, April 24, 2020 at 10:15 am. Detailed information about the convention will be available in early 2020... visit https://ohpsych.org/page/convention for the most up-to-date.

In an effort to shed light on this very confusing issue, OPA’s Insurance Committee has created an Audit Toolkit. This tool kit is free to all members (and may be purchased by non-members) and offers a checklist of clinical record details considered critical by most insurance companies. While individual companies may vary somewhat in terms of their requirements, most follow an industry standard which is set by the Centers for Medicare and Medicaid Services. These standards require that testing and psychotherapy services must be medically necessary if they are to be reimbursed by health insurance companies, and that the record of these services must include certain details to document this medical necessity. The record itself must establish a consistent connection between symptoms present, diagnosis, treatment plan goals, and tasks of psychotherapy sessions. (This connection is sometimes referred to as the “Golden Thread.”)  During audits, insurance companies often look for documentation of these details to establish medical necessity, and have been known to reclaim funds paid for services when this necessity is not established to their satisfaction. 

OPA’s Insurance Committee has taken all these factors into consideration in creating their toolkit checklist. It is quite likely that its use when creating clinical records will help any clinician face an insurance company audit with confidence. OPA members may click here to access their FREE toolkit. My hope is that members will find this member benefit useful. As always, please feel free to reach out to me with question and suggestions.

Jim Broyles, PhD
Director of Professional Affairs, Ohio Psychological Association
jbroyles@ohpsych.org

APA has provided resources to educate psychologists on the use of the new codes. Presently, the most accessible is a webinar available on YouTube entitled “Getting Reimbursed: Testing Code Changes are Here” by Antonio Puente, PhD and Neil H. Pliskin, PhD. 

View webinar here: https://www.youtube.com/watch?v=Q1kAZEgih2w

This 1 hour webinar gives a good overview of the use of the new codes and should help any psychologist feel more prepared for the coming change.

OPA members should also stay aware of the timing of their billing. While your APA and OPA leadership has been working to ensure that insurance companies are aware of and ready for the coming changes, unfortunately there is no guarantee that all individual companies will be fully prepared. Typically, big changes such as this require them to make significant systems changes. History has demonstrated that sometimes these changes are executed smoothly but sometimes not. Billers of psychological testing services will maximize their chances of avoiding confusion and unnecessary reimbursement delays by paying very care attention to the timing of their billing. All psychological testing services rendered in 2018 should be billed by December 31, 2018, so that all billing sent in 2019 will be for testing service provided January 1, 2019 and beyond. This approach may circumvent some issues with readiness the respective insurance companies may experience.

Please feel free to email me with questions or for additional resources.

During my time providing help and support around insurance issues, I have noted that I often end up working directly with many practice office managers. Recently, one of our insurance committee leaders, Dr. Leslie McClure, suggested that OPA find a way to help office managers interact directly with each other, or with me. From this concept, a new FREE member benefit was born: OPA should have a separate listserv specifically for office managers. With the help of OPA Director of Membership Carolyn Green, we now have that listserv available. 

Our vision for this listserv is that it will be a tool for those who do regular insurance billing, whether they are small practice psychologist, office manager, or office billing specialist. The topics of discussion will be questions or suggestions pertaining to billing practices, CPT codes, diagnostic codes, pre-authorizations, etc. I and other insurance committee members will monitor the listserv closely to serve as a resource for users. 

Each OPA member may designate ONE individual or email address to be part of the group. If you feel you or your office personnel would benefit from joining this list, I encourage you to sign-up using our online form.

Should you have any questions about this new listserv, please contact OPA at 614-224-0034 ext. 11, or email me.

• Be in writing and in print sufficiently large to ensure that the client is able to read the contract
  
• Clearly state whether the psychologist is excluded from Medicare.
  
• State that the client or his or her legal representative accepts full responsibility for payment for the physician’s or practitioner’s charge for all services furnished by the psychologist.
  
• State that the client or his or her legal representative understands that Medicare limits do not apply to what the psychologist may charge for items or services furnished by the psychologist.
  
• State that the client or his or her legal representative agrees not to submit a claim to Medicare or to ask the psychologist to submit a claim to Medicare.
  
• State that the psychologist or his or her legal representative understands that Medicare payment will not be made for any items or services furnished by the psychologist that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
  
• State that the client or his or her legal representative enters into the contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that the client is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out.
  
• State the expected or known effective date and expected or known expiration date of the opt-out period.
  
• State that the client or his or her legal representative understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
  
• Be signed by the client or his or her legal representative and by the psychologist.
  
  

Once a psychologist has opted out, the opt out status lasts for two tears, and is renewed automatically at the end of the two-year period. The opt out status may not be terminated during that period unless the provider is opting out the very first time. In that case, the opt out may be terminated within the first 90 days of the period. These opt outs may be cancelled by notifying Medicare before 30 days prior to the beginning of the next two tear period. 

Medicare offers a handout available in PDF format summarizing these requirements, including an opt out affidavit form. It can be downloaded here: https://www.cgsmedicare.com/partb/enrollment/part_b_optout.pdf

Completed affidavit forms should be sent to:

CGS Administrators, LLC
J-15 Part B Provider Enrollment
PO Box 20017
Nashville, TN 37202

I can also be contacted directly for a copy of this handout. 

My hope is that this summary answers most questions for our members on this topic. However, I understand questions about specific situations may arise.  Please feel free to reach out to me directly (jbroyles@ohpsych.org) if you need more individualized support.

Jim Broyles, PhD
Director of Professional Affairs
Ohio Psychological Association

For example, at one point I was part of a discussion involving psychological services and billing codes.  As is often the case, the conversation began to focus on which services were reimbursed by insurance companies (a topic of discussions I am frequently involved in).  One of my colleagues reminded me that a separate billing for use of screening instruments was allowed by most insurance companies.  I realized that many psychologist, especially folks in private practice, were unaware of or taking advantage of this.  My next idea was that I need to make sure I am passing this information on to OPA members.

My hope is that more psychologists are becoming aware of the importance of measuring and documenting the effectiveness of their work through outcome measures, particularly those who are practicing psychotherapists.  The use of screening instruments can help accomplish this task.  Screening instruments such as Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7), Alcohol Use Disorders Identification Test (AUDIT-C), are commonly used to detect the presence of symptoms and can be used pre, during, and post intervention.  While insurance companies vary on how frequently the use of these measures can be reimbursed, most provide some reimbursement for screening procedures when billed along with initial assessment or psychotherapy codes.  

As a result of requirements created by the Affordable Care Act, CPT Code 96127 was created in 2015.  Defined as brief emotional/behavioral assessment, with scoring and documentation, per standardized instrument, this code may be billed along with an initial assessment or psychotherapy code for each instrument administered.  Though in many cases the reimbursement rates are nominal, regular use of this procedure can create some added income for many practitioners.  Doing so also provides an incentive for clinicians to begin outcome measurement for their work.  For those of you who regularly use screening or brief assessment instruments, I encourage you to remember to bill CPT 96127 along with your regularly used code(s).  For those of you who do not make regular use of screening, I encourage you to start.  As always please reach out to me (jbroyles@ohpsych.org) with questions and comments.

• Inform your current clients be sure to leave adequate time for termination or referral.
• Talk to the psychologists to whom you will refer clients who need ongoing treatment — find out about their availability, insurance accepted, location, office hours and areas of expertise
• Ensure continuity of care by providing referrals to clients who require ongoing services and helping them with the transition
  
• Obtain informed consent and transfer a copy of your clients' records to the new providers
  
• Inform your clients other health care professionals and keep them up-to-date on the status of closing your practice
  
• Attempt to notify your past clients. There are a number of approaches you might take, including sending a letter and/or placing a notice in the local papers of the area you serve, on your website and in other community forums. Be sure to include information about how to contact you or access client records.
• Be mindful of records you are required to maintain.  Ohio rule regarding this:

OAC 4732-17-01 (B) Negligence:
(7) Maintenance and retention of records.
(b) To meet the requirements of these rules, but not necessarily for other legal purposes, the license holder shall ensure that all contents in the professional record are maintained for a period of not less than seven years after the last date of service rendered, or not less than the length of time required by other regulations if that is longer. A license holder shall retain records documenting services rendered to minors for not less than two years after the minor has reached the age of majority or for seven years after the last date of service, whichever is longer.

• Identify a person who will maintain current records you are required to keep and protect their confidentiality.  Make sure you have an updated written plan to facilitate the transfer of these records, and that the person who knows the location of this plan is identified by you to the Ohio Board of Psychology.  Ohio rule regarding this:
  

OAC 4732-17-01 (B) Negligence
(7) Maintenance and retention of records.
(c) A license holder shall store and dispose of written, electronic, and other records of clients in such a manner as to ensure their confidentiality. License holders shall prepare in advance and disseminate to an identifiable person a written plan to facilitate appropriate transfer and to protect the confidentiality of records in the event of the license holder's withdrawal from positions or practice. Each license holder shall report to the board on the biennial registration (renewal) form the name, address, and telephone number of a license holder or other appropriate person knowledgeable about the location of the written plan for transfer and custody of records and responsibility for records in the event of the licensee's absence, emergency or death. The written plan referenced in this rule shall be made available to the board upon request.

• After securely storing the records you are required to maintain, clear any electronic protected health information off computers, PDAs and cell phones. See information about the Health Insurance Portability and Accountability Act (HIPAA) Security Rule for requirements regarding record storage and destruction.
  
  

Finances

• Talk to your attorney and accountant to determine whether selling your practice is a viable and worthwhile option. Also, be aware of ethical issues related to selling your practice, and seek appropriate consultation as necessary
  
  
• If selling your practice, decide whether to work with a broker to help you navigate this potentially complicated process that requires a sophisticated understanding of local and state laws, business valuation, marketing strategy, tax implications and contracts
  
  
• Collect any accounts receivable
  
  
• Pay off any outstanding debts

• Work with your accountant to organize your financials records (e.g., financial reports, tax documentation, contracts)
  
  
• Talk to your accountant and/or tax professional about the tax implications of closing or selling your practice and strategies to reduce your tax liabilities
  
  
• Once all of your finances have been reconciled, close bank accounts associated with your practice
  
  

Business Issues

• Discuss the arrangements with your partners — if selling or transferring your ownership to your partner(s), be sure to work closely with your attorney to protect all parties involved
  
  
• Inform your office staff far in advance
  
  Notify all your referral sources
  
  Inform other professional contacts and relevant entities, including the psychology board, professional organizations, insurance panels and other parties with which you contract, your billing and answering services and other practice consultants 
  
  
• If you rent office space, give notice to terminate your lease in the manner and time frame that your leasing contract requires. If you own, take steps to sell or rent your office
  
  
• Sell, donate or dispose of office equipment, such as photocopiers, fax machines, and furniture. Remember that if any of this equipment contains confidential information, that information must be deleted in line with HIPAA requirements.
  
  
• Use up any remaining office inventory
  
  
• Contact the issuers of any business licenses and permits you hold
  
  
• Cancel any utilities (e.g., electric, gas, water, phone, Internet) you pay for your office
  
  
• Submit a change of address form with the post office. Depending upon your privacy concerns and where you want your professional mail delivered, you may want to consider obtaining a post office box for a period of time to make sure you do not miss any important correspondence
  
  
• Cancel or forward any publications or subscriptions you received at your office
  
  
• Forward your office telephone number or keep you answering service for a period of time. Place an outgoing message informing callers of your closure and giving instructions for contacting you or accessing their records
  
  
• Call your professional liability insurance carrier — make sure you are covered for complaints filed after you close your practice. If your current policy does not cover this type of complaint, find out about purchasing a "tail" to your policy 
  
  

I hope you find this helpful.  For those of you who are more experienced with this process, please feel free to contact me with more tips others might find helpful.


Jim Broyles, PhD, OPA Director of Professional Affairs

This information is also available in a pdf version in the Professional Resources section of our website located under the Member Services tab. 
Note... This is a members' only restricted area. You will need to login to gain access to the Professional Resources page.

Behavioral Health Redesign is now in effect as of 1/1/2018 and Optum has identified a growing trend of inappropriate billing according to the Ohio Department of Medicaid’s coding specifications. A significant number of claims are being submitted and denied “A17 | NPI not Billed” because the NPI is not being reported on each detail line. Behavioral Health Redesign coding specifications indicate this is a requirement. 

For specific reference to this requirement, providers should visit: http://bh.medicaid.ohio.gov 
Provider > Manuals, Rates & Resources > IT Resources (Final) > EDI/IT Q&A Document

UHCCP reports that providers are not able to submit claims with rendering NPI at the line level through the UHC claims portal. This portal does not have the capacity to submit claims in this format.  Claims in this format will have to be sent paper claim or through a clearinghouse.

If you bill United Health Care Community Plan and you have questions about this, please feel free to email me.

Jim Broyles, Ph.D.,  OPA Director of Professional Affairs

• Make preauthorization forms available electronically
  
• Allow preauthorization forms to be submitted electronically
  
• Respond to requests for authorization within
  
  • 48 hours for urgent situations
    
  • 10 days for nonurgent situations
    
• List preauthorization requirements on the company’s website 
  
• Provide a streamlined appeal process including reasonable timelines for denied authorizations
  
• Prohibit retroactive denial of authorizations granted
  

In the past, I have provided support for a number of psychologists who were requesting help with obtaining preauthorization for testing or for an extended therapy session time. This law would affect the processes involved here, requiring them to be clear and accountable. 

Please feel free to give me feedback about what you are encountering as you interact with insurance companies. Are you finding these features available from insurance companies on their websites?  Are you aware of law violations?  

I welcome your questions as well as your feedback.

Letter recipients have reached out to me expressing concern and confusion regarding the purpose of the letter.  Most feel confused about the meaning of the above statements. In an effort to help, I reached out to Anthem and asked for more information. In their response, Anthem clarified: “our letter is strictly educational in nature and its purpose is to ensure that your documentation supports the codes that are being billed.” Their response continues by outlining the documentation they would expect to see to support the CPT 90837 service billed:

• Date of service
• Length of session (start/end time), therapy time with patient and/or family
  
• Therapeutic maneuvers utilized
  
• Diagnosis -for each visit- related to treatment and therapy for the visit 
  
• Progress or lack of progress to the goals
  
• Updates to treatment plan if necessary
• Provide signature (Electronic or written)

Also to note, these services are NOT included in the “time” for the session:

• Time spent arranging services/appointments
  
• Time spent in communication with other healthcare providers
  
• Time spent documenting or providing reports
  

The intent of the letter, then, is to remind recipients to follow documentation guidelines for CPT Code 90837. No information was given on whether record audits should be expected at some point in the future. However, it seems clear that following these guidelines should help Anthem providers pass audits with no issue. I would also like to note that these record keeping guidelines are very similar to current standard accepted practices for the insurance industry and to recommendations I have given in the past.  

I hope you find this helpful.  Please feel free to stay in touch should you have other issues or concerns.

Jim Broyles, PhD
OPA Director of Professional Affairs

I reminded him of Ohio law on this topic, which I am copying below.  Insurance companies may look back and make a new determination about previously paid claims, but they are limited to a two-year period.  In other words, a request for return of paid claims is limited to the two-year period immediately preceding the notice requesting the return of funds.  The following is taken from the Ohio Department of Insurance website:

Adjustments of Previously Paid Claims

Claim payments that are made on or after July 24, 2002, are deemed final two years after the payment is made. After that date, the amount of the payment is not subject to adjustment, except in the case of fraud by the provider. 
 
A third-party payer may recover the amount of any part of a payment that the third-party payer determines to be an over-payment if the recovery process is initiated not later than two years after the payment was made to the provider. 
Upon determination of an over-payment a third-party payer shall send a notice to the provider that contains the following:

1. The full name of the beneficiary who received the health care services for which over-payment was made;
   
2. The date or dates the services were provided;
   
3. The amount of the over-payment;
   
4. The claim number or other pertinent numbers;
   
5. A detailed explanation of basis for the third-party payer's determination of over-payment;
   
6. The method in which payment was made, including, for tracking purposes, the date of payment and, if applicable, the check number;
7. That the provider may appeal the third-party payer's determination of over-payment, if the provider responds to the notice within thirty (30) days;
   
8. The method by which recovery of the over-payment would be made, if recovery proceeds under division (B) of this section.

Please note number seven above which allows for an appeal of the re-determination.  I urged the psychologist who reached out to me to appeal the adjustment determination, including a copy of the above information.

I hope you find this reminder helpful.  Please feel free to let me know whether you have encountered similar difficulties and about any problems you had responding to such requests.  

The first of these is Ohio’s Prompt Payment Law, which establishes strict time frames for the processing and payment of claims by insurance companies.  Specifically, the law states:

1. A third-party payer has fifteen (15) days from receipt to notify a provider when a materially deficient claim is received. Examples of materially deficient claims include claims with an incorrect patient name or benefit contracts number, a patient that cannot be identified, a claim without as or treatment code or a claim without a provider's identifying number. The fifteen (15) day time period and the time spent correcting the deficiencies do not count toward the calculation of time in which a claim must be processed.
2. A third-party payer has thirty (30) days to process a claim if no supporting documentation is needed.
3. A third-party payer has forty-five (45) days to process a claim if the third-party payer requests additional supporting documentation. However, third-party payers must request supporting documentation within thirty (30) days of the initial receipt of the claim. The time period of forty-five (45) days is suspended until the third-party payer receives the last piece of information requested in the initial thirty (30) day period.
   • The time period is not suspended if a third-party payer requests additional supporting documentation after receiving initially requested information.
   • A request for additional supporting documentation that is made outside the thirty (30) day time period and that is based on information received in the initial request regarding a previously unknown pre-existing condition may suspend the forty-five (45) day processing time.
4. A third-party payer may refuse to process a claim submitted by a provider if the provider submits the claim later than forty-five (45) days after receiving notice from a different third-party payer or a state or federal program that that payer or program is not responsible for the cost of the health care services, or if the provider does not submit the notice of denial from the different third-party payer or program with the claim.
5. A third-party payer that has a timely filing requirement must process an untimely claim if all the following apply:
   • The claim was initially submitted to a different third-party payer or state or federal program;
   • The provider submits the claim to the second payer within forty-five (45) days of receiving notice that the first payer denied the claim; and
   • The provider submits the notice of denial along with the claim
6. When a claim is submitted later than one year after the last date of service for which reimbursement is sought, a third-party payer shall pay or deny the claim not later than ninety (90) days after receipt of the claim or, alternatively, pursuant to the requirements of sections 3901.381 to 3901.388 of the Revised Code.

Many reimbursement issues encountered by psychologists may be eligible for a complaint under this law.  For example, an insurance company may review a claim to determine whether it was medically necessary.  However, they may not withhold payment, beyond the time frames stipulated, while making this determination.  The timelines above still apply.  

If you need to file a Prompt Pay Law complaint or any other complaint with the Ohio Department of Insurance (ODI), the best way is to establish an ODI Provider Gateway Account.  Once established, filing complaints with ODI becomes streamlined.  Instructions for establishing this account with ODI may be found here:
https://legacy.insurance.ohio.gov/ODILogon/Legacy/content/Documents/PC/ProviderGatewayAccount.pdf

I encourage all psychologists who interact with insurance companies to establish this account with ODI.  Providers may also use a printed form:
http://www.insurance.ohio.gov/forms/documents/INS0505.pdf

It may be helpful to share this information with office managers.  They may contact me directly for questions and support, providing they work for an OPA member.  In the next few weeks, I will be providing information on more laws associated with these core issues of difficulty affecting many of us.  In many cases, the solution may involve interacting with ODI, so following the above suggestion will facilitate my recommendations in the future. (Please note: ODI does not govern Medicaid or Medicare plans.  Please contact me directly for help with these).

Please let me know if you have comments or questions.

Jim Broyles, PhD
OPA Director of Professional Affairs

Recently, a number of insurance companies have begun to restrict or limit the use of certain codes. For example, some require preauthorization for the 60-minute code, while others have sent warning letters to clinicians who “overuse” this longer session time. Together with OPA’s insurance committee, I have been monitoring this circumstance and have felt considerable concern about the reasoning behind the emergence of these newer policies. Specifically, many of the insurance companies have justified these restrictions by reasoning that most clinicians do not use longer session times routinely. This idea stands in direct contradiction to information gathered informally by OPA’s Insurance Committee and me. Through conversation and email, many of you have reported you consider the 60-minute psychotherapy session crucial to your treatment approach with clients. Others have stated they would use the 60-minute session much more often, but are unable to due to insurance company restrictions.

In response to these confusing and contradicting circumstances, OPA’s Insurance committee has developed their own survey. The purpose of the survey is to gather accurate, objective information about psychotherapy CPT codes commonly used by psychologists and others. The survey takes only a minute or two to complete, and the results will be used to help advocate for our members on this issue. It would be enormously beneficial to our efforts if you will take that minute to participate in our survey now:

https://www.surveymonkey.com/r/XKLMWQ9

It would also be quite helpful if you would pass along the link to the survey to other mental providers in your practice or community. I will be happy to report survey results as well as other efforts related to this issue as they develop. 

On a related note, many psychologists who are Medicaid providers have been experiencing confusion regarding the implementation of Medicaid Behavioral Health Redesign. The proposed redesign changes were initially scheduled to be implemented July 1 of this year. Due to a number of concerns expressed about readiness by community mental health providers, the implementation of the redesign has been postponed.  Ohio Department of Medicaid will continue the existing mental health and substance use disorder service codes, billing logic, rates and policies until a future date for Behavioral Health Redesign implementation is determined. However, qualified Ohio hospitals who offer outpatient community behavioral health services may begin implementing the new behavioral health code set and policies beginning August 1, 2017. Please let me know if you would like further details. The Ohio Department of Medicaid will also continue staffing its Rapid Response telephone lines (1-800-686-1516, Option 9) in order to respond to questions from providers.

Jim Broyles, PhD, OPA Director of Professional Affairs

You may be receiving a very important survey soon from the American Psychological Association Practice Organization. The surveys will be emailed to APAPO members, and will be gathering vital information regarding the valuation of Current Procedural Terminology (CPT) codes commonly used by psychologists, which directly affects reimbursement rates set by all insurance companies. The survey is developed by the American Medical Association /Specialty Society Relative Value Scale Update Committee (RUC). Click here to view an article from a recent APAPO Practice Update which explains the survey. It is very important for you, if you are a member of APAPO, to be on the lookout for the survey and to set aside the 2 hours it may take to complete it. If you have questions feel free to contact me.

On a related note, I received many positive comments about my last communication with OPA members regarding the letters from Change Healthcare. This group contacted psychologists regarding their billing practices and use of certain CPT codes. In that communication, I outlined concerns expressed by APAPO and OPA to Change, as well as gave specific recommendations on how to respond to their requests. During our recent OPA Convention and through email, many of you pointed out how helpful this information was. I feel compelled in response to point out to everyone that the guidance from that communication would have been impossible if not for the considerable efforts of APAPO’s office of Legal and Regulatory Affairs, specifically attorneys Alan Nessman and Connie Galietti. Both expended considerable time and effort communicating with the organizations in question, drawing on their considerable legal experience and expertise, to produce the guidance you received. This is only a small example of the ongoing advocacy and support Ohio psychologists receive from APAPO. Many psychologists today remain unaware of the vital support they receive from APAPO, and how our more local advocacy efforts are dependent on their help. I urge all Ohio psychologists to be mindful of this when making a decision on whether to become a member of this organization.

In the past, the Legal and Regulatory Affairs staff of the American Psychological Association’s Practice Organization (APAPO) has reached out to Change Healthcare to seek clarification of their intent in sending these letters in other states. During those discussions APAPO raised many issues about the letter. For example, APAPO staff noted that outpatient mental health practice lends itself more to the use of the longer 90837 code, while codes representing shorter time periods are more likely to occur in nursing homes or integrated care facilities. As a result, those psychologists who were allegedly high users of 90837 might not necessarily have been high users if they were compared to other psychologists in a typical outpatient practice. Furthermore, APAPO staff noted that the nature of these letters could give a chilling effect and dissuade psychologists from using the procedure codes most appropriate for their patients. 

Change Healthcare clarified for OPA and APAPO that the intent of these letters was truly to be educational (although we believe that this educational project was unnecessarily anxiety producing). Change Healthcare does not presume that a higher use of 90837 involves inappropriate billing. We learned that here will be no routine audit of those who use 90837 at a higher rate than other psychologists. Nor will Change Healthcare initiate any unusual efforts toward seeking refunds from psychologists who use the 90837 codes more frequently than others. 

Can Psychologists Continue to Bill Medical Mutual 90837?
Psychologists should continue to use their clinical judgment to determine the health care needs of their patients, including the length of a psychotherapy session. At this time, we are not aware of Change Healthcare limiting the use of 90837. We recommend that psychologists billing 90837 with Medical Mutual continue to use its billing guidelines as described in the next section. According to official guidance for CPT codes, 90834 (psychotherapy, 45 minutes with patient and/or family member) is to be used for sessions lasting 38-52 minutes. Code 90837 is to be used for sessions that are 53 minutes or more in duration. In addition, 

• Psychotherapy times are for face-to-face services with the patient and/or family member.
  
• The patient must be present for all or some of the service.
  
• In reporting, choose the code closest to the actual time (i.e., 53 or more minutes for 90837).
  
• Document start and end times.
  

Following this guidance should put psychologists in a good position if Change Healthcare later decides to review their records and/or practices. 

Finally, OPA members can contact me if their experiences with Highmark appear contrary to the guidelines described above.

Please note: Legal issues are complex and highly fact specific and require legal expertise that cannot be provided by any single article. In addition, laws change over time and vary by jurisdiction. The information in this article does not constitute legal advice and should not be used as a substitute for obtaining personal legal advice and consultation prior to making decisions regarding individual circumstances.

Current Procedural Terminology (CPT®) copyright 2015 American Medical Association. All rights reserved.

1. Make sure the initial consent document used in your practice includes language designed to provide consent for releasing patient information in response to a broad array of insurance company requests.
   
   For example:
   You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record.... By signing this Agreement, you agree that I can provide requested information to your carrier.
   
   This allows for the release of basic clinical information which may be required by the insurance company.
   
   
2. HIPAA allows for psychotherapy notes to be kept separate from the rest of a client’s clinical record, and offers a greater level of protection for these notes.  I suggest psychologists maintain this separate record. This allows for less sensitive, more basic clinical information to be easily released in response to an insurance company audit while offering greater protection for client privacy.
   
   
3. Most insurance companies require that we follow basic record keeping guidelines set primarily by Medicare. When billing time based CPT codes, the more general clinical record should include documentation which supports the procedure (separate from the psychotherapy note) for each session billed including:
   

• Session start and stop time
• Modality
  
• Diagnosis
  
• Symptoms
  
• Functional Status
  
• Focused Mental Status Exam
  
• Treatment plan goal addressed, prognosis, and progress
  
• Name, signature, and credentials of the person performing the service
  
  

Following these suggestions will help many psychologists to readily respond to most audits conducted by insurance companies for the variety of reasons that I am familiar. More detailed guidelines on record keeping will be provided during my workshop at OPA’s upcoming convention (Thursday, April 27 at 9:00 a.m.). I hope to see you there! 

Jim Broyles, PhD
OPA Director of Professional Affairs

I am coming to realize very quickly that I must maintain two high priorities as your DPA: 1) to monitor, learn about, and provide support for the everchanging challenges which emerge for psychologists as you interact with the world of insurance companies; and 2) communicate often and clearly my best understanding of how to navigate these rough waters.  My intention is to do this through emails such as this, as well as through my blog on the OPA website and our social media.  If insurance issues affect you, look for these communications and feel free to contact me and give feedback.

As those of you who follow the OPA’s general listserv know, my efforts to help with these insurance issues have been required in the last two weeks.  Many psychologists who are Medical Mutual providers have received letters from Change Healthcare, a company who has contracted with the insurance carrier to provide auditing for them.  The form letter received by our members essentially expressed concern that some psychologists are overbilling psychotherapy code 90837.  Those of us who have worked with insurance issues for some time recognize these letters as the latest example of a larger effort on behalf of the entire insurance industry to discourage the use of a commonly used psychotherapy session time (CPT 90837—60 minutes) and encourage the use of a shorter one (CPT 90834—45 minutes).  As so many of our many members have observed, these efforts have been ongoing absent any clearly articulated research or clinical effectiveness based rational.  

Fortunately, at the state and national level, we have experience working with this issue.  In 2016, another insurance carrier, Anthem Blue Cross Blue Shield, made similar efforts through an auditing company with whom they contracted, EquiClaim.  A number of letters similar to those sent out by Change Healthcare were received by our members from EquiClaim in early 2016. Following this, OPA reached out to APA’s office of Legal and Regulatory Affairs.  Their staff attorneys were able to intervene with Anthem, and the results were positive.  These results were summarized in an article published on APA’s website in March, 2016:

Practice Organization members have reported receiving letters about the frequency of their use of CPT® code 90837 (psychotherapy, 60 minutes with patient and/or family member). These letters, sent by EquiClaim on behalf of Anthem Blue Cross Blue Shield, were addressed to psychologists allegedly using 90837 more than average for Anthem psychologists.

The letters indicate they are for informational purposes; however additional language states EquiClaim’s monitoring of the psychologist’s 90837 billing practices may lead to a request for “medical records of members with the intention of identifying any improper coding and recovering associated overpayments.” Members expressed concern that continued use of 90837 might result in an audit and refund demands.

Practice Legal and Regulatory Affairs staff has developed a good relationship with leaders at Anthem. Using a collaborative approach (which proved successful with the Santé Analytics and Inovalon audits), we contacted Anthem to clarify the meaning and intent of the EquiClaim letters. Anthem promptly provided a statement (PDF, 102KB) assuring us that this is an educational process without financial consequences. 

In response to our concerns about these letters, Anthem has made changes internally to ensure further reviews of these types of communications occur in advance of distribution.

As I write, these same APA staff attorneys are reaching out Medical Mutual representatives in an effort identify similar solutions.  I will be happy to keep you updated on their results.  (I remind myself that this is the reason I pay my APAPO dues!)

I look forward to continuing these regular communications with you.  Feel free to share your thoughts!

Jim Broyles, Ph.D.
OPA Director of Professional Affairs

1. Contact your representative (Click here to find your representative.)
   
2. Express your concern, particularly if you worried about individuals who may be negatively impacted if important benefits are cut.
   
3. Most importantly: tell a story about someone you know who has been helped by the benefits extended by the ACA or who may be seriously harmed if these benefits are lost. The Senator’s assistant urged us to not underestimate the power of these stories.