Resources

This section includes resources for CliniciansUNITED members. Check back often for updates.

NEWS: End Clawbacks for Mental Health Treatment

Bill limiting insurance clawbacks is key step toward addressing access to mental health care

BOSTON, MA – Today, private mental health clinicians organized through SEIU Local 509’s CliniciansUNITED campaign are testifying before the Joint Committee on Financial Services in favor of legislation to limit retroactive claims denials by insurance companies. This practice, known as clawbacks, is in effect a subtle way for insurance companies to deny critical behavioral health care.

Currently, insurance companies can recoup their payments to a clinician months, or even years, after a therapy session takes place and is paid for, even though therapists secure prior approval from health insurance companies before treating their patients, and then adhere to billing deadlines (usually 60 or 90 days after each session takes place). No similar deadline exists for insurance companies. As a result, companies have demanded that private mental health clinicians pay back thousands of dollars for services rendered years ago in good faith.

The financial burden and uncertainty created by unlimited clawbacks has a chilling effect on therapists and is a limiting factor on their ability to treat patients. More and more clinicians are choosing to leave insurance panels because they find the requirements, the reimbursement rates, and retroactive claims denials too difficult to accept. If there are fewer therapists accepting insurance, people seeking mental health and substance abuse services have a harder time finding qualified therapists to work with at fees they can afford.

“In order to tackle the crisis in access to affordable mental health care, we have to address the insurance practices that are limiting providers’ ability to treat their patients,” said Erica Kirsners, a clinician and social worker in Brookline. “We clinicians treat our patients in good faith and in accordance with the insurance information we have.  Insurance companies should also have to act in this good faith and in the spirit of our mental health access laws.”

CliniciansUNITED supports legislation introduced by Representative Jim O’Day and Senator Michael Rodrigues (H.2193/S.582) that would limit insurance companies to a six-month window for retroactive claims denials.

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CliniciansUNITED is a multidisciplinary group of behavioral health clinicians who are associate members of the Massachusetts Human Service Workers Union, SEIU Local 509. Together, we are fighting to ensure each and every Bay State resident has access to quality, affordable mental health services — and to bring about the fair reimbursement policies and practices needed to make universal access possible.

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New Legislative Session

The new legislative session got underway in January. We will be updating this page with revised fact sheets with updated bill numbers once they become available.

The Clawback Bill

This bill establishes fair parameters around the health insurance practice of reverting payments (clawbacks) for which providers of behavioral health services had received previous authorization and been paid by health insurers.

Our Legislation will: Limit both MassHealth and commercial health insurers to a six-month period for recovering payments to a behavioral health provider for behavioral health services completed.

Click here for more information on the Clawback Bill (H2193).

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Members Meet with Congressman Kennedy

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Last week, CliniciansUNITED members met with Congressman Joe Kennedy III to discuss how we can work together to tackle the mental health care access crisis in Massachusetts and throughout our country.

The opportunity to meet with Congressman Kennedy came after our own published response to his well-received letter in the Herald News, where he outlined his current legislative efforts to tackle our country’s “systemic inadequacies deeply entrenched across the entire continuum of mental healthcare.”

From recognizing insurance companies’ high mental health claim denials (nearly twice the rate of physical health claims), to tracing how lowered provider reimbursement rates have stunted mental health care access, our conversation focused on how we can collaborate to make progress on these access issues in Massachusetts and across the country.

We also shared our progress on current state-level legislative initiatives to even the playing field between clinicians and insurance companies, along with our survey data illuminating the systemic barriers Massachusetts providers currently face.

CliniciansUNITED hopes to keep the conversation going with Congressman Kennedy, coordinating state level and federal initiative to truly expand mental health care access here in the commonwealth and beyond.

See more pictures from the meeting here.
Read CliniciansUNITED member Heather Grosso’s published letter here.

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Experienced delays in your BCBS/HMO payments? We have answers!

BCBS LogoIn recent weeks, many clinicians have reported delays in receiving payments from Blue Cross Blue Shield (BCBS) HMO plans. Calls to BCBS left several clinicians with even more questions — from the cause of the delays to exactly when they might expect  to see payment.

Our union, CliniciansUNITED / SEIU Local 509, reached out to our contacts at Blue Cross to get to the bottom of this weeks-long delay, and the insurer issued a Managed Care Behavioral Health Provider Update (see below).


BCBS HMO MANAGED CARE BEHAVIORAL HEALTH
PROVIDER UPDATE

A 2016 calendar year system enhancement to automate the processing of Managed Care Behavioral Health services is in the final implementation stage. The change will improve the accuracy and timeliness of Managed Care Behavioral Health claims in support of the first 12 visits not requiring authorization.

Managed Care claims for dates of service after 1/1/16 will be released by the end of February. There is no impact to PPO Behavioral Health Claims.


Based on what we’ve learned, CliniciansUNITED expects the final pieces of this ‘system enhancement’ to be implemented by the end of February — so providers should see payments no later than the beginning of March. Some clinicians may see reimbursements as early as this week.

As many clinicians have pointed out, some claims will have passed the 45-day statutory limit by the time everything is sorted out. We have ensured that Blue Cross Blue Shield is aware of statutory requirements to pay interest on these claims.

While we now have answers and a firm timeline, there is still work to do. We will need to hold BCBS accountable to its stated deadlines — and we will work to make sure every clinician receives any interest owed. 

Click here if you have faced challenges with Blue Cross Blue Shield HMO claims in recent weeks.

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Clawback Testimony

In December of 2015, CliniciansUNITED members, staff, and bill sponsor Representative Jim O’Day testified in support of House Bill 925, An Act to Limit Retroactive Denials of Health Insurance Claims for Mental Health and Substance Abuse Services. This bill will:

• Limit both MassHealth and commercial health insurers to a six month period for recovering payments to a provider for services completed. When providers deliver a service in good faith and in compliance with eligibility rules, they should be compensated without fear of insurance companies taking back these reimbursements years or months after the services were provided.

• Require that MassHealth institute a back-end process to reconcile payment between payers without involving the provider. This process could mirror the current process in the auto insurance industry.

To read our submitted testimony, click here

For more information about the bill, click here for the fact sheet. 

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HB 925 Clawback Bill Fact Sheet

CU’s third priority bill is House Bill 925, An Act to limit retroactive denials of health insurance claims for mental health and substance abuse services. Health insurance companies have the ability to audit and take back reimbursements ( often called “clawbacks”) given to health care providers for services rendered, sometimes years in the past. The process for doing this is not transparent and has a chilling effect on how health care providers practice and the access to services. Currently, many other states have statutes on the books that protect health care providers from this practice.

This bill will:

• Limit both MassHealth and commercial health insurers to a six month period for recovering payments to a provider for services completed. When providers deliver a service in good faith and in compliance with eligibility rules, they should be compensated without fear of insurance companies taking back these reimbursements years or months after the services were provided.

• Require that MassHealth institute a back-end process to reconcile payment between payers withoutinvolving the provider. This process could mirror the current process in the auto insurance industry.

Click here to view the clawback bill (HB925) fact sheet.

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Report of the Working Group on Medicaid Managed Care Organizations

This past month, the Medicaid Managed Care Organization (MCO) Working Group, convened in June by Speaker of the House, Robert A. DeLeo (D-Winthrop), and chaired by State Representative Jeffrey Sánchez (D-Boston), House Chair of the Joint Committee on Health Care Financing, released their report on the status of Medicaid MCOs in Massachusetts.

The 13 member Working Group was charged with reviewing the delivery of Medicaid benefits by the MCOs, including cost-drivers and potential savings. This report covered many topics including behavioral health integration and alternative payment methodologies. There are many noteworthy pieces of this report, but one small section stood out. When discussing the challenges of rate setting (in general, not just for behavioral health), the relationship between antitrust laws and transparency presented a challenge:

“During Working Group discussions about provider contracts and pricing, the MCOs indicated that they could not discuss specific provider rates and contracts due to antitrust laws. Other stakeholders responded that price transparency would not violate antitrust laws. The system should not be paying providers radically different prices for the same services of comparable quality. There was some frustration from the Working Group because complete transparency is needed to fully understand the current issues and make policy recommendations.”

Click Here to read the full MCO Working Group Report

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Anti Trust & Transparency Legislative Fact Sheets

Senate Bill 649, An Act to promote the accessibility, quality and continuity of care for consumers of behavioral health, substance use disorder and mental health services was filed in January of 2015 by Sen. Dan Wolf. This bill addresses access challenges by creating state action immunity for providers who choose to engage in joint negotiations with insurance providers on issues such as reimbursement rates and medical necessity criteria.

Click here to view the fact sheet on reform initiative SB649. 

House Bill 1812, An Act to promote accessibility and affordability of behavioral health and substance abuse services for recipients of MassHealth was filed in January 2015. This bill, filed by Rep. Jim O’Day,  will require mental health carve-outs to make their contracts and executive compensation publicly available. The purpose of this bill is to shine a light on how effectively tax dollars are being spent to provide essential behavioral health and substance abuse services to those that need them most.

Click here to view the fact sheet on reform initiative HB1812

 

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ICD-10 Transition Helpful Tips

As we all know, we are changing to ICD-10 for billing. Below are some reminders, links and facts to help with the transition.

1. Use ICD-10 diagnostic codes for Dates of Service (DOS) October 1st and later.

  • Be sure to use ICD-9 codes for all DOS in September and ICD-10 codes for all DOS in October and later – no matter when you submit the claim. If you submit a claim on 10/5 for a session on 9/28, use the ICD-9 diagnostic code.
  • Do not submit a bill on one CMS-1500 form that includes both DOS prior to 10/1 and DOS 10/1 or later.
  • Use ICD-10 codes on requests for prior auths for DOS 10/1/15 and later.  You do NOT need to submit a new auth request simply to change to the ICD-10 diagnosis if your current auth spans the 10/1 date.
  • When submitting on the CMS-1500 paper claim form, do NOT use the period in the diagnosis.
    With online billing, continue to do what you have been doing for each particular insurance company.

2. When submitting ICD-10 codes on the CMS-1500 paper claim form, be sure to change the “9” to “0” on line 21, “ICD Ind.”

3. This change to ICD-10 and DSM-5 will have no effect on the CPT codes, keep using the same CPT codes (90836, 90791, 90847 etc).

4. The DSM-5 manual is very helpful. It lists all the ICD-10 codes (in parentheses, in gray) right next to the descriptive DSM diagnoses. If you have not yet purchased it, you can order by phone, 800.368.5777 or online, www.appi.org/Home.  It is also available at http://www.valore.com/about-us/valorebooks/

DSM-5 has several crosswalks from ICD-9 to ICD-10:

  • An alphabetical listing of all diagnoses with their ICD-9 (what we used to call DSM-IV) codes and ICD-10 codes; and
  • A numerical listing of all the ICD-10 codes and their DSM-5 diagnoses.
5.  Here are easy online crosswalks to use – type in the ICD-9 code (“DSM” code) you are currently using, and either site will give you the corresponding ICD-10 code:
http://www.icd10data.com/Convert
http://www.nuemd.com/icd-10/codes

6. Unfortunately, the available version of DSM-5 has some mistakes. There is a correction sheet on page 3 of the APA Coding Update: http://dsm.psychiatryonline.org/pb/assets/raw/dsm/pdf/DSM-5%20Coding%20Update_Final.pdf

It appears that only 3 changes apply to the codes we generally use (most of the changes pertain to neurocognitive issues). Of note, the 3 diagnoses we might use:

  • Bipolar I Disorder, hypomanic, in partial remission should be F31.71
  • Bipolar I Disorder, hypomanic, in full remission should be F31.72
  • Adjustment disorders should now be specified as ACUTE (less than 6 months) or PERSISTENT/CHRONIC (6 months or longer).  This is a significant change from DSM-IV.
  • Put all specifiers  – for any diagnosis – in your chart, but not on the claim form.
    There is no ICD-10 code that differentiates acute from persistent adjustment disorder.

7. There may be reimbursement delays during the early months of implementation of ICD-10. Billing services, clearing houses and the insurance companies themselves may have a rocky start.  We hope not.

8. Other than that, don’t stress. Most of the brouhaha over ICD-10 appears to be because the medical (not the psychiatric) diagnoses have mushroomed, and now necessitate a much greater degree of specificity. ICD-9 had approximately 13,000 codes; ICD-10 has approximately 68,000 codes.  But the number of codes in mental health, about 700, has barely increased.

9.  Once we learn to how to translate the codes for the diagnoses we tend to bill – and there are plenty of very easy crosswalks to use – billing will be simple. The DSM part, what we note in our charts, is a little more complicated, but as we use it, we will become conversant with it.

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Medical Necessity Testimony for Health Policy Commission

In August, CliniciansUNITED submitted testimony to the Health Policy Commission on proposed changes to medical necessity criteria. You can read the full request for testimony with description of  the proposed changes here. A snippet of our testimony:

“Clinicians spend an inordinate amount of unpaid time on the phone and completing online authorizations with insurance companies making the case for why their clients meet medical necessity requirements to continue treatment. The insurance representatives have never met the client, yet they make the decision on whether or not treatment is approved. How is this the standard of care that we are working toward keeping?”

To read CU’s full submitted testimony, click here.

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