Article submitted by: Jim Broyles, PhD, OPA Insurance Committee – Chair 

OPA’s insurance committee met on 1/7/15.  We continue to welcome questions and concerns from OPA members.  Individuals who wish to contact the insurance committee should do so by emailing opainsuranceissues@gmail.com.   Please feel free to include as much information about your question or concern as possible.

The Insurance Committee has been reviewing issues concerning Medicare PQRS and the reimbursement penalty assessed by Medicare for not meeting criteria.  OPA staff recently discussed concerns regarding this issue with our Medicare contact.  Specifically, the question of measures available appropriate for use by psychologists was raised.  Many psychologists who are Medicare providers do not feel there are enough measures available for our use.  In response to our query, our Medicare representative stated:

Professionals (EPs) are to find nine measures that apply to what they do in the office. If they are unable to find nine measures, they are required to report on the number of measures that do apply.  EPs are not penalized if they cannot find nine.  Instead, CMS does a Measure Applicability Validation (MAV), which is a process where an audit is done on the EPs claims history to ensure there were no additional opportunities to report on more measures than were reported.  If an EP can find only three measures, the MAV process verifies this before assessing a penalty.  If the process proves only three measures applied, no penalty is assessed.   Additional info on this is available under “2014 PQRS” located at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/AnalysisAndPayment.html. 

Further information about appropriate measures to use is available from APA:

http://www.apapracticecentral.org/medicare/pqrs/faqs/index.aspx

Please feel free to contact the insurance committee if you have questions or concerns about this process.

OPA is also currently gathering information on problems encountered by psychologists on getting approval for testing.  The association would like to assess the extent to which psychologists have encountered difficulty with getting insurance companies to approve or reimburse for testing needed by their clients.  Please contact the committee if you have information to share in regarding this concern.

Insurance committee outreach message:

OPA’s Insurance Committee meets once a month, the first Thursday of the month at 8:00 am.  We are currently welcoming new members.  OPA members who are experiencing difficulty with insurance or billing issue may also attend a meeting to discuss their issue with the committee.

The committee currently is gathering information on the extent to which members who bill insurance companies for services are having claims rejected due to problems with diagnosis or CPT code.  Psychologists often contact the association to report that a given diagnosis is not covered by an insurance provider, or that a CPT code is not available for them to use or requires preauthorization.  The Insurance Committee would like to hear from you if you are affected by these issues.

A number of members are experiencing questions or have confusion about Medicare Fraud, Waste, and Abuse training being required by Medicare or, in particular, Medicare contractors.  If you have concerns with this issue, you are encouraged to contact the committee.

If you would like to communicate with the committee about these or other issues, please email: opainsuranceissues@gmail.com.