Teaching mental health providers how to navigate the managed care industry and increase cash flow

HIPAA

MHPChat Recap – Building Your Practice on a Budget

Posted by on Jul 21, 2014 in Bootstrapping, Business, Entrepreneur, HIPAA, Mental Health, Practice Management, Psychotherapy, Social Media | 0 comments

MHPChat Recap – Building Your Practice on a Budget
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HIPAA, Mental Health, and Managed Care

Posted by on Dec 3, 2013 in HIPAA, Managed Care, Mental Health, Psychotherapy | 0 comments

ID-100213905There is a labyrinth of regulations called HIPAA that mental health and medical professionals have to navigate in order to remain in business. The Health Insurance Portability and Accountability Act of 1996 was established to create standards related to the creation and maintenance of electronic health records. It was also meant to regulate how Protected Health Information is used. Here’s why this is important. If a patient is being seen for a medical or mental health issues, they need to feel confident in the knowledge that their information won’t be sent to their employer. Or what if the patient is going through a divorce and/or child custody hearings? How likely are patients to be honest with their doctor or counselor if there is constant fear that their PHI will become public knowledge.

In my experience, medical and mental health professionals are very diligent about protecting the confidentiality of the client. However, there is an exclusion in HIPAA that many mental health professionals and the general population is not fully aware. It’s called the Treatment Payment Operations (TPO) HIPAA Exclusion. The exclusion states that if a patient is using insurance, then he is allowing the insurance company to obtain information from provider and coordinate care. The key words being “if the patient is using the insurance.” This applies whether the mental health provider participates in the plan or not. If you are a mental health provider and you participate or are “in-network” with that patient’s plan, typically you have a contractual obligation to coordinate care with the insurance company. Out of network providers do not have the same obligation. However, managed care companies can refuse to pay due to a lack of information. Think of it in terms of getting a loan from a bank. If a long standing customer walks into a bank and asks for a loan, the bank will want certain information from the customer to see if they qualify. The customer can say “You don’t need that information. I’ve been a customer for years. Just give me the loan.” But the bank reserves the right to not grant the loan based on a lack of information. Or based on the information given, doesn’t meet guidelines for being granted a loan. Using insurance benefits works in much the same way. In order to receive reimbursement, the care has to meet the guidelines. In order to see if the care is meeting the guidelines, insurance companies may ask for additional information regarding the patient’s care including a treatment plan and a plan for discharge.

In my time working in managed care, I have heard objections that it’s a violation of HIPAA to request such information. Well, from the TPO exclusion, it is not. The key is that managed care companies require the minimal necessary information to make a decision based on HIPAA. Typically, this includes the diagnosis, the treatment plan, the progress, and discharge plan. Some companies require this information in writing while other require a telephonic review. But the overall goal of the review is to determine if the care is meeting the guidelines, not to deny benefits.

So if you are a mental health provider and you are in a situation that requires you to give a clinical review to the managed care company, remember that it does not violate HIPAA to do so. I would recommend that if your patient is using insurance, you inform them at the beginning of treatment that their insurance may ask additional questions regarding their treatment and that using insurance gives the insurance company the right to request the information. It is also advisable that you have a proper release of information on file as well. This protects both you and the client. Also remember that insurance companies are not required to share information with employers due to HIPAA as well.

If you’re a mental health provider and you have had trouble getting along with managed care companies, let me help you. Many mental health providers just don’t have the time to learn the rules of how insurance works and become frustrated due to not getting paid in a timely manner. I can help you navigate the managed care industry and increase your cash flow. For more info, contact me at 321-800-8520   Image courtesy of Stuart Miles at FreeDigitalPhotos.net

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5 Things Psychotherapists and Clients Should Know About Insurance

Posted by on Sep 9, 2013 in Aetna, BCBS, Cigna, HIPAA, Insurance, Managed Care, Providers, Psychotherapy | 0 comments

Though I don’t discuss it much, my foundation comes from psychotherapy. I have worked on the client side and the managed care side. Both have their pros and cons, but I wanted to take the time to dispel some notions about managed care. This is for the benefit of both providers and patients/clients alike.

1. Your Employer Determines Your Benefits – Even though you are paying a premium, your employer determines what is covered in the plan and how the plan is managed. And your employer is paying a larger share of the premium than you are. Insurance is not cheap, and nowadays most employers are seeking plans that are cost effective. That means benefits that were fairly generous 2 or 3 years ago are becoming less generous today.

2. Unlimited Sessions? – Many plans are set up without session limits. However, the plans are managed in such a way that after so many sessions, a utilization review will likely occur. If the provider is asked for a utilization review, the managed care company is trying to determine if the treatment offered is meeting clinical guidelines or medical necessity. Unfortunately, a lot of providers are unaware of the guidelines or don’t understand how to properly apply the guidelines. This can lead to waste, fraud, and abuse which causes premiums to increase due to a few bad actors. Guidelines are available online or upon request for each managed care company.  Here are a few below:

3. HIPAA TPO Exclusion – HIPAA law (45 CFR Part 164, Subpart E – Privacy of Individually Identifiable Health Information) allows insurance companies to exchange “necessary” information with your provider for treatment or payment as long as you are using the benefit. If you are using the benefit, you are in effect giving your permission for the exchange of information to occur. As long as you are using the benefit there is no HIPAA violation if the insurance company is contacting your provider for a review of your case. You can refuse to allow your provider to speak with the insurance company about your case, but the insurance company can deny benefits due to a lack of information. Let’s say you went to your bank for a loan, but refused to give them any information as to why you need the loan or how you intend to pay it back. Chances are you will be denied for the loan, because the bank doesn’t have enough information to make a decision. The same principle applies to your benefits. 
4. Out of Network Providers Do Deal with Insurance Companies – If you are an out of network provider, but your clients use insurance, you will deal with insurance companies. Especially if your client wants to be reimbursed. It may include doing a clinical review to authorize services. If you are a provider who doesn’t want to deal with insurance companies, don’t take clients who use insurance.
5. There is No Reimbursement for Talking to Insurance Companies – If the provider is asked to do a review to justify services, the insurance company will not reimburse the provider for that time. If the provider is in network, he cannot bill the client for that time, unless there is already a written agreement in place that the client will pay for time talking to managed care. If the provider is out of network, they can bill the client for that time. (Personally, I would not see a provider who would charge me for speaking with the insurance company, especially if the provider believes the treatment is necessary. That’s just the cost of doing business.)

Image courtesy of Ambro at FreeDigitalPhotos.net

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