Medicare and Government Regulations

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As a mental health professional, you answer patients’ questions about more than their care. Many patients are also concerned about payment. Knowing how to answer questions about Medicare, insurance and other payment questions is an important part of services offered by mental health practices. A strong knowledge of government regulations and Medicare also ensures compliance and reduces the possibility of incorrect billing.

There is certainly a need for quality information about mental health and Medicare mental health services. In 2013, about 43.8 million adults in the U.S. – or about 18.5 percent of the adult population were living with some type of mental illness. About 1 in 17 American adults lives with a serious mental health issue. In 2008, 13.4 percent of the US adult population received some form of treatment for mental illness. These forms of treatment include medication as well as inpatient and outpatient care.

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Mental Health Providers and Medicare

Many types of mental health and psychiatrist treatment are covered under Medicare Part B. Your patients’ services may be partly or fully covered under Medicare Part B (Medical Insurance) if you are a:

  • Clinical social worker
  • Doctor, psychiatrist, or doctor of osteopathy
  • Nurse practitioner or clinical nurse specialist
  • Physician assistant
  • Independently practicing psychologist
  • Clinical psychologist
  • Certified nurse-midwife

If you are one of these types of mental health professionals, patients may be able to use Medicare to pay for therapy, counseling and other visits if you accept assignment. If a patient approaches you about scheduling a visit and they are paying through Medicare, you will want to tell them whether or not your practice accepts assignment. If you do not, your patients may not be able to use Medicare Part B to pay for visits.

What Constitutes Medicare Covered Psychologist Treatment?

The mental health treatment covered by Medicare Part B is quite specific and includes:

  • No more than one depression screening annually, done at a primary care clinic or doctor’s office
  • Testing to assess the effectiveness and appropriateness of current treatment
  • Diagnostic tests (including neuropsychological testing)
  • Family counseling (but only if for the purpose of helping with mental health treatment)
  • Medication management
  • Narcosynthesis
  • Hypnotherapy
  • One-on-one activity therapy (for mental health treatment, not for recreation)
  • Group or one-on-one psychotherapy
  • Psychoanalysis
  • Biofeedback therapy
  • ECT (Electroconvulsive Therapy)
  • Psychiatric evaluation and diagnostic meetings
  • No more than one visit to evaluate risk of depression
  • No more than one annual visit to evaluate changes to mental health from one year to the next
  • Visits to administer drugs that cannot be administered by the patient
  • Partial hospitalization

You will not be able to bill Medicare for patient services that include:

  • Support groups
  • Testing for job skills (where the tests are not part of a patient’s mental health treatment)
  • One-on-one psychophysiological treatment involving biofeedback training
  • Pastoral or marriage counseling
  • Geriatric day programs and activities
  • Care or meetings concerning environmental intervention
  • Interpreting or explaining test results or preparing reports
  • Telephone, meal or transportation services

Approved mental health services are covered if they are provided in:

  • An outpatient clinic offering mental health care
  • A private office
  • A hospital outpatient clinic
  • Adult day care center

The patient will pay their yearly Medicare Part B deductible ($147 as of 2014) and 20% of the amount Medicare approves for the treatment or visits. If you offer your services as part of a hospital outpatient department or clinic, your hospital will charge the patient a coinsurance amount or copay, usually amounting to 20-40% of the amount approved by Medicare for the treatment. If you are a psychologist, you may be able to bill patients 40-50% of the amount approved by Medicare. The program covers less of the costs associated with treatment offered by a psychologist. In some cases, however, a Medigap supplemental insurance policy (if a patient has it) will pay for some of these costs.

Medicare Part A can help your patients cover their hospital bills. If you work in a hospital setting and treat patients who have been hospitalized, your patients may be able to use Medicare Part A to pay for all or part of their mental health services.

If you prescribe medication as part of mental health treatment, your patients may be able to use Medicare Part D to pay for their medication. If your patients are being billed under Medicare Part B, you or someone on your staff may wish to speak with them about medication costs and about Medicare coverage of medicine costs.

Understanding Assignment and Medicare Payment for Mental Health Services

Assignment is an area that often causes confusion. If you are a Medicare participating mental health professional and accept assignment for your services, the assignment payment needs to be accepted for all Medicare patients and for all services covered by Medicare. You cannot, in other words, choose to accept assignment payments for only some services or some patients covered under Medicare.

In addition, mental health professionals who don’t participate in Medicare can still accept payment in some cases. If you choose not to accept assignment and don’t participate in Medicare, payment will be 95% of the current PFS amount under Medicare. If you are Medicare-certified but don’t accept assignment, you will be able to bill patients 15% above the amount approved by Medicare. Your patients will pay this amount, as well as the 20% coinsurance.

Services provided by clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, physician assistants, and certified nurse-midwives are always made under assignment, even when these professionals decide not to take part in the Medicare program.

If you accept assignment, you:

  • Will be paid the amount allowed by Medicare for approved services as your full payment
  • Will not be able to seek anything other than coinsurance, copayments or deductibles from your patients

Outpatient Hospital Services for Mental Health

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To be covered by Medicare, outpatient hospital services need to be:

  • Administered under a formal and personalized written POC (Plan of Care) outlining the diagnosis, treatment, goals and other information about the outpatient care
  • Medically needed or reasonable to help the patient’s condition or diagnose the patient
  • Correctly evaluated and supervised by a physician

Many services are covered by Medicare in an outpatient environment, including diagnosis and many types of treatment, activity therapies and occupational therapies.

The following services are not covered:

  • Any group or activity therapies designed mostly for recreation
  • Some psychosocial activities (mostly those that are social in nature)
  • Transportation and meals
  • Training and vocational training for definite job opportunities

Mental Health, Partial Hospitalization and Medicare

Medicare may cover partial hospitalization for mental health treatment if the partial hospitalization is organized by a Community Mental Health Center (CMHC) or hospital. In general, practitioners may be able to bill Medicare for partial hospitalization and related services in cases where patients are hospitalized for less than 24 hours a day and where they are either at risk of needing inpatient care or have been released from inpatient treatment. In general, patients need to take part in at least 20 hours per week of care to qualify for partial hospitalization. As with outpatient services, a written plan of care is needed and the goal needs to be to make measurable progress in the patient’s condition.

Partial hospitalization services are only permitted in situations where patients require more intensive mental health treatments or supervision. Often, this treatment option is chosen for patients with mental health conditions severe enough to significantly affect multiple areas of their life. Partial hospitalization is permitted in cases where a patient is able to take part in treatment actively.

Mental Health Professionals Opting Out of Medicare

There is evidence that a growing number of physicians and mental health professionals are choosing to opt out of Medicare. In 2012, 9,539 doctors opted out of Medicare after previously being part of it. In 2009, about 3,700 physicians opted out of Medicare. In 2012, about 685,000 physicians were participating in Medicare. In 2010, about 83% of doctors accepted new Medicare patients, compared to 81% in 2012. While only a small fraction of doctors opt out of Medicare entirely, psychiatrists represent the largest number of medical professionals who choose to opt out. They account for over 41% of all medical professionals who have chosen to opt out.

There are many reasons why a growing number of doctors are opting out of Medicare. Some are frustrated by slow pay times, low pay and Medicare rules. For instance, in 2015 some doctors will face penalties if they don’t offer quality measures to the government or switch to digitized medical records. Some doctors and psychiatrists want to have more control over their practices than they feel Medicare offers, while others have concerns about billing practices or privacy policies under the program. Doctors and psychiatrists who opt out of Medicare rely on direct payment from patients or private insurance for reimbursement.

Non-Medicare Government Regulations Mental Health Professionals Should be Aware of

Medicare is a common government program mental health professionals deal with in their work, but Social Security Disability is another. Many patients come to mental health professionals when applying for Supplemental Security Income or Social Security Disability Insurance benefits. It’s important for professionals to understand their role in the claims process.

As a mental health professional, you may receive Form SSA-827 (Authorization to Disclose Information to the Social Security Administration). This form lets you release medical records. Your name does not need to appear specifically on Form SSA-827 for you to be authorized to release records. Usually, the request for medical information and records will come from your state’s Disability Determination Services (DDS) or another agency in your state responsible for handling claims made to the Social Security Administration (SSA).

In addition, you or your practice may receive requests for additional information or evidence if a patient has appealed an SSA decision about acclaim. The request may come from a judge from the Office of Disability Adjudication and Review of the SSA.

You can submit records electronically if you choose, which can reduce processing times. No matter how you submit information, it’s important to submit the full information requested and to submit information promptly. It’s also important to submit the most accurate information possible. About 53% of SSA claims are denied, and about 72% of first claims are denied, often because patients are not able to prove disability with medical evidence. Providing full, accurate and timely information will help your patients with their claim.

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You do not have to submit session or process notes, but you are authorized by Form SSA-827 to release all medical reports and records. If you keep notes separate from patient medical records, you can simply submit the medical records without the notes. If you incorporate the notes, you can black them out or create a separate medical record to send.

When you send medical records and other information as part of a request from the SSA or state agency responsible for SSA claims, the information will be treated confidentially. The SSA will not share the information you provide with other parties or agencies without written consent. The only exception is that some very limited information you provide may be shared under federal or government laws.

Keeping Up with Medicare and Government Rules

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The rules for Medicare and payments change regularly. For an example of the depth of these rules, consult the latest Payment Policies for Medicare. Changes are made quite frequently. For example, in 2014 changes were made to the reimbursement of medical and some mental health professionals who provided telehealth and digital health services.

Since mental health services lend themselves well to interactive telecommunications, it is an area of special interest to this field. Under the new regulations, mental health professionals offering digital health and telehealth services to qualified Medicare patients in rural health professional shortage areas (HSPAs) may be reimbursed for these services.

In 2014, a number of services were added to the covered telehealth model, including psychotherapy services and annual wellness visits. If your practice is considering adding telehealth or digital health services, you may wish to explore the latest changes to the reimbursement model.

Where Mental Health Providers Turn for Medicare, Billing and Government Regulation Assistance

For more than twenty years, mental health professionals have relied on Benefits Processing Services (BPS) for assistance with their billing needs. A division of Summit Technologies, Inc., BPS is a billing company specializing in behavioral therapy and mental health fields. As a full-service billing company, we offer services to non-profit, group and individual clients.

We make sure you enjoy better control over your billing process and your practice, freeing your time and reducing the number of partial or rejected payments. We work to ensure all claims for reimbursement are submitted correctly and with correct coding. When rejections happen, we take a close look at rejected claims and re-submit where reimbursement is possible. Our goal every step of the way is to save you hassle while ensuring a healthier revenue stream.

We keep up with government and Medicare regulations so you don’t have to. At BPS, we know your focus is your patients. We stay up to date with the many complex rules and laws of billing, copays and medical insurance so you can focus on what you do best.

We offer both services and software for practitioners interested in improving their cash flow and benefits. Schedule a demonstration of our software today to see the program our clients claim improves their cash flow by more than 25%.