Q: I read in the private practice resource newsletter, Psychotherapy Finances (September 2006), that managed care and insurance rates are being reduced. What can the American Counseling Association do to help? What should we do? Drop all managed care contracts? Go for client fee for service? HELP!
A: Dropping all managed care contracts and accepting only fees paid by clients is one way to handle the problem. But doing that cuts out many clients who have paid into their insurance and expect to be able to use it for mental heath counseling. In many demographics, our practices would dry up unless our niches occupied the upper end of the income spectrum.
I (Bob) read the article you cited and did some investigating. I called Aetna, Value Options, United Behavioral Health, Magellan, Horizon Behavioral Health, ACI Specialty Benefits and Oasis Health Care. These are a fairly good representative sample of managed care and insurance companies. All their provider relations people assured me that they were not planning on reducing fees.
I then politely asked each one if there was a way to get an increase in reimbursement. After some negotiations, Aetna offered me a 12 percent increase. Value Options made no promises but said it is reviewing a possible increase across the country in 2007. United Behavioral Health said it would consider a reimbursement increase if I sent a request in writing outlining my reasons. Magellan will also be reviewing an increase in rates for 2007. Horizon offered me an increase from $65 to $70, while ACI gave me a raise from $60 to $67. Oasis is giving me a $5 raise to $70 on employee assistance programs and $75 on regular managed care.
Psychotherapy Finances reports that the companies it contacted will not deal with national organizations such as ACA, the American Psychological Association and the National Association of Social Workers. ACA Special Projects Coordinator Martha McIntosh has certainly tried.
Here is why this must be a grass-roots movement. First, it worked! I negotiated and received reimbursement increases. Second, if hundreds of counselors call managed care provider relations, you may not all get increases, but the managed care and insurance companies will certainly get the message that we are in need of better reimbursement rates.
One call came to me from a reader suggesting a class-action lawsuit or otherwise raising hell with the companies. We have found, and have proved, that polite inquiry and persistence work better. A list of the largest managed care and insurance companies is available on the ACA website (from www.counseling.org, click on “Counselors,” then “Private Practice Pointers” and “Provider Relations Contact List”).
Do it! Call your managed care companies and ask. Remember, we encourage our clients to take risks to improve. Shouldn’t we? Also, please e-mail us about your experiences with managed care contracts, both bad and good.
NPI, NPI, NPI. We are still receiving many questions about the National Provider Identifier. HIPAA mandates that all health care professionals use an NPI beginning May 23.
Q: How do counselors switch from using provider ID numbers to the National Provider Identification when billing insurance and managed care companies using the standard insurance claim form?
A: Basically, three issues need to be addressed. First, you should be receiving forms from insurance and managed care companies by now requesting your NPI. While the deadline for compliance is not until May 23, many of the larger companies (Blue Cross/Blue Shield, United Healthcare, United Behavioral, Value Options, etc.) are gearing up now to be ready by that date. Please note that many companies will have their own protocols and timelines for converting from provider ID numbers to the NPI.
While it should go without saying, read the letters from the managed care and insurance companies asking for your NPI number, and make sure you follow each company’s protocol until the deadline. When submitting your NPI, do not forget to send the form in with a copy of the NPI confirmation letter or e-mail you received from the National Plan and Provider Enumeration System.
Second, after submitting your NPI to insurance and managed care companies, your NPI has to be included on all third-party billing no later than the deadline. This also requires you to obtain the new CMS-1500 (HCFA) health insurance claim form (approved August 2005). The difference between the old CMS-1500 and the new form is box 24J, where your NPI number is required. The new CMS-1500 forms are available from Medical Arts Press (www.medicalartspress.com), Safeguard Forms (815.539.7279) or your local OfficeMax.
Third, you will need to contact your practice software vendor to upgrade your billing program to accommodate the NPI and new CMS-1500 form. All major software vendors should have this upgrade available currently or very soon.
Q: We have been a member of ACA for many years and are in need of some assistance. We are attempting to file for a National Provider Identifier. After reviewing much of the information on the CMS website, we still are unsure of how to proceed. We are a very small clinic with one full-time and three part-time counselors on staff. Does each individual counselor need to apply for his or her own NPI, or do we apply for one NPI under the clinic? If each counselor needs an NPI and the clinic also needs one, which NPI do we bill under? We are also having some difficulty determining our taxonomy code from the diverse selection. Thank you for your assistance in helping us deal with this mandate.
A: There is a way to apply for an institutional NPI, but each therapist has to have his or her own number. Call the NPI hotline (866.282.0659) for questions related to aspects of the NPI legislation and regulation or other HIPAA-related matters. The NPI Enumerator may be contacted by calling 800.465.3203 or 800.692.2326 (TTY). I have called several times, and they have been very helpful.
Questions regarding the use of the NPI in health plan billing should be directed to the individual managed care and insurance health plan. Billing issues may have to be addressed to the managed care and insurance companies individually. You may be able to also clarify these issues with NPI.
We provide a list of the 55 major managed care and insurance companies with direct links to the provider relations page of their websites. This is available to members on the ACA website. From www.counseling.org, click on “Counselors,” then “Private Practice Pointers” and “Provider Relations Contact List”.
We are also including the taxonomy website (www.wpc-edi.com/taxonomy) and a copy of the taxonomy codes used for counselors.
Behavioral Health and Social Service Providers:
E Counselor: 101Y00000X
- Addiction (Substance Use Disorder): 101YA0400X
- Mental Health: 101YM0800X
- Pastoral: 101YP1600X
- Professional: 101YP2500X
- School: 101YS0200X
E Marriage and Family Therapist: 106H00000X
E Psychoanalyst: 102L00000X
E Psychologist: 103T00000X
- Addiction (Substance Use Disorder): 103TA0400X
- Adult Development and Aging: 103TA0700X
- Clinical: 103TC0700X
- Clinical Child and Adolescent: 103TC2200X
- Cognitive and Behavioral: 103TB0200X
- Counseling: 103TC1900X
- Educational: 103TE1000X
- Exercise and Sports: 103TE1100X
- Family: 103TF0000X
- Forensic: 103TF0200X
- Group Psychotherapy: 103TP2701X
- Health: 103TH0004X
- Health Service: 103TH0100X
- Men and Masculinity: 103TM1700X
- Mental Retardation and Developmental Disabilities: 103TM1800X
- Prescribing (Medical): 103TP0016X
- Psychoanalysis: 103TP0814X
- Psychotherapy: 103TP2700X
- Rehabilitation: 103TR0400X
- School: 103TS0200X
- Women: 103TW0100X
E Social Worker: 104100000X