CPT codes: Let a hundred lawsuits blossom

The American Psychiatric Association (APA) started working with insurance companies prior to the new CPT codes taking effect. Some have responded by making the appropriate adjustments so that patients and psychiatrists billing for E&M codes (Evaluation & Management) as well as the new psychotherapy codes are paid properly and fairly. In most cases, when this is paid according to the law – including the parity law – the payments are higher than they were before the codes went into effect on Jan. 1, 2013.

However, there are still many insurance companies that have either ignored the law, or, more malignantly, have taken advantage of the situation by paying patients and physicians even less money for needed mental health and addiction treatment than they did before Jan. 1. Many psychiatrists, state psychiatric societies, and the APA are fighting with the payers to correct this improper, even illegal, corporate behavior.

Psychiatrists across the country have been confused and angered by this behavior, some even blaming the APA for supporting the changes. However, most are now realizing that it is the insurance companies that are playing games. Well, the games are over, the gloves are off, and the complaints and lawsuits are beginning to fly.

In January, the Centers for Medicare and Medicaid issued a strongly worded statement to state health officers that their Medicaid plans need to be compliant with Parity.

On March 11, the New York State Psychiatric Association filed a federal lawsuit against UnitedHealth contending that it systematically discriminates against people with mental illness by limiting, delaying, and denying care, including discriminatory payment practices.

On March 14, the APA, Connecticut Psychiatric Society, and Connecticut State Medical Society sent a letter to Anthem Blue Cross, which they believe is “violating state and federal laws and regulations, including the Mental Health Parity and Addiction Equity Act (MHPAEA), the Connecticut Parity Law, HIPAA, and the Unfair Insurance and Unfair Trade Practices laws as they pertain to the treatment of patients with a mental or substance use disorder.”

Sam Muszynski, director of APA’s Office of Healthcare Systems and Financing, enumerated the problems being seen across the country:

“Unfortunately, the apparent inability of many payers to at least maintain the reimbursement levels psychiatrists were receiving in 2012 has created a number of problems for APA members and their patients. The problems seem to differ from plan to plan and even from psychiatrist to psychiatrist within a plan’s network. Some of the issues the Office of Healthcare Systems has heard about with some regularity are:

• Plans’ inability to process the two codes now needed to represent psychotherapy with medical evaluation and management (E/M), previously coding using one code with minimal value given to the E/M, which is often a major part of psychiatric care. There are variations on this with some plans paying only for the E/M code, while others pay only for the psychotherapy code.

• Plans paying for the two codes, but at such reduced fees that psychiatrists are receiving less than they did for providing the same services in 2012 when they had no means of accurately representing the E/M work they performed.

• Plans charging patients two co-pays for a visit with a psychiatrist because two codes are used to record the visit – something that never occurs with visits to primary care physicians who often use several codes for apatient encounter.

• Plans requiring prior authorization for the use of E/M codes 99214 and 99215.

• Plans not paying anything at all because of computer problems with processing the claims.

• Plans refusing to recognize and/or pay for the psychotherapy add-on codes (90833, 90836, and 90838).

“We have an ongoing program of liaison with payers regarding these issues and are launching a new focused effort aimed at amelioration,” Muszynski said. “Where resolution is not forthcoming, the APA will commence an even more focused action with the problem payers and will consider all appropriate options as necessary.”

We need to get lawsuits against this illegal behavior blossoming in every state. The best thing we can do is to complain to the payers, our state psychiatric societies, our state insurance administrations, and our elected officials. Add your voice to the strength of the APA by sending it your evidence of improper or illegal insurance discrimination. See the box for more information.

—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on at drdavisATgmail.com, and  and on the Shrink Rap blog.

The American Psychiatric Association (APA) started working with insurance companies prior to the new CPT codes taking effect. Some have responded by making the appropriate adjustments so that patients and psychiatrists billing for E&M codes (Evaluation & Management) as well as the new psychotherapy codes are paid properly and fairly. In most cases, when this is paid according to the law – including the parity law – the payments are higher than they were before the codes went into effect on Jan. 1, 2013.

However, there are still many insurance companies that have either ignored the law, or, more malignantly, have taken advantage of the situation by paying patients and physicians even less money for needed mental health and addiction treatment than they did before Jan. 1. Many psychiatrists, state psychiatric societies, and the APA are fighting with the payers to correct this improper, even illegal, corporate behavior.

Psychiatrists across the country have been confused and angered by this behavior, some even blaming the APA for supporting the changes. However, most are now realizing that it is the insurance companies that are playing games. Well, the games are over, the gloves are off, and the complaints and lawsuits are beginning to fly.

In January, the Centers for Medicare and Medicaid issued a strongly worded statement to state health officers that their Medicaid plans need to be compliant with Parity.

On March 11, the New York State Psychiatric Association filed a federal lawsuit against UnitedHealth contending that it systematically discriminates against people with mental illness by limiting, delaying, and denying care, including discriminatory payment practices.

On March 14, the APA, Connecticut Psychiatric Society, and Connecticut State Medical Society sent a letter to Anthem Blue Cross, which they believe is “violating state and federal laws and regulations, including the Mental Health Parity and Addiction Equity Act (MHPAEA), the Connecticut Parity Law, HIPAA, and the Unfair Insurance and Unfair Trade Practices laws as they pertain to the treatment of patients with a mental or substance use disorder.”

Sam Muszynski, director of APA’s Office of Healthcare Systems and Financing, enumerated the problems being seen across the country:

“Unfortunately, the apparent inability of many payers to at least maintain the reimbursement levels psychiatrists were receiving in 2012 has created a number of problems for APA members and their patients. The problems seem to differ from plan to plan and even from psychiatrist to psychiatrist within a plan’s network. Some of the issues the Office of Healthcare Systems has heard about with some regularity are:

• Plans’ inability to process the two codes now needed to represent psychotherapy with medical evaluation and management (E/M), previously coding using one code with minimal value given to the E/M, which is often a major part of psychiatric care. There are variations on this with some plans paying only for the E/M code, while others pay only for the psychotherapy code.

• Plans paying for the two codes, but at such reduced fees that psychiatrists are receiving less than they did for providing the same services in 2012 when they had no means of accurately representing the E/M work they performed.

• Plans charging patients two co-pays for a visit with a psychiatrist because two codes are used to record the visit – something that never occurs with visits to primary care physicians who often use several codes for apatient encounter.

• Plans requiring prior authorization for the use of E/M codes 99214 and 99215.

• Plans not paying anything at all because of computer problems with processing the claims.

• Plans refusing to recognize and/or pay for the psychotherapy add-on codes (90833, 90836, and 90838).

“We have an ongoing program of liaison with payers regarding these issues and are launching a new focused effort aimed at amelioration,” Muszynski said. “Where resolution is not forthcoming, the APA will commence an even more focused action with the problem payers and will consider all appropriate options as necessary.”

We need to get lawsuits against this illegal behavior blossoming in every state. The best thing we can do is to complain to the payers, our state psychiatric societies, our state insurance administrations, and our elected officials. Add your voice to the strength of the APA by sending it your evidence of improper or illegal insurance discrimination. See the box for more information.

—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on at drdavisATgmail.com, and  and on the Shrink Rap blog.

The American Psychiatric Association (APA) started working with insurance companies prior to the new CPT codes taking effect. Some have responded by making the appropriate adjustments so that patients and psychiatrists billing for E&M codes (Evaluation & Management) as well as the new psychotherapy codes are paid properly and fairly. In most cases, when this is paid according to the law – including the parity law – the payments are higher than they were before the codes went into effect on Jan. 1, 2013.

However, there are still many insurance companies that have either ignored the law, or, more malignantly, have taken advantage of the situation by paying patients and physicians even less money for needed mental health and addiction treatment than they did before Jan. 1. Many psychiatrists, state psychiatric societies, and the APA are fighting with the payers to correct this improper, even illegal, corporate behavior.

Psychiatrists across the country have been confused and angered by this behavior, some even blaming the APA for supporting the changes. However, most are now realizing that it is the insurance companies that are playing games. Well, the games are over, the gloves are off, and the complaints and lawsuits are beginning to fly.

In January, the Centers for Medicare and Medicaid issued a strongly worded statement to state health officers that their Medicaid plans need to be compliant with Parity.

On March 11, the New York State Psychiatric Association filed a federal lawsuit against UnitedHealth contending that it systematically discriminates against people with mental illness by limiting, delaying, and denying care, including discriminatory payment practices.

On March 14, the APA, Connecticut Psychiatric Society, and Connecticut State Medical Society sent a letter to Anthem Blue Cross, which they believe is “violating state and federal laws and regulations, including the Mental Health Parity and Addiction Equity Act (MHPAEA), the Connecticut Parity Law, HIPAA, and the Unfair Insurance and Unfair Trade Practices laws as they pertain to the treatment of patients with a mental or substance use disorder.”

Sam Muszynski, director of APA’s Office of Healthcare Systems and Financing, enumerated the problems being seen across the country:

“Unfortunately, the apparent inability of many payers to at least maintain the reimbursement levels psychiatrists were receiving in 2012 has created a number of problems for APA members and their patients. The problems seem to differ from plan to plan and even from psychiatrist to psychiatrist within a plan’s network. Some of the issues the Office of Healthcare Systems has heard about with some regularity are:

• Plans’ inability to process the two codes now needed to represent psychotherapy with medical evaluation and management (E/M), previously coding using one code with minimal value given to the E/M, which is often a major part of psychiatric care. There are variations on this with some plans paying only for the E/M code, while others pay only for the psychotherapy code.

• Plans paying for the two codes, but at such reduced fees that psychiatrists are receiving less than they did for providing the same services in 2012 when they had no means of accurately representing the E/M work they performed.

• Plans charging patients two co-pays for a visit with a psychiatrist because two codes are used to record the visit – something that never occurs with visits to primary care physicians who often use several codes for apatient encounter.

• Plans requiring prior authorization for the use of E/M codes 99214 and 99215.

• Plans not paying anything at all because of computer problems with processing the claims.

• Plans refusing to recognize and/or pay for the psychotherapy add-on codes (90833, 90836, and 90838).

“We have an ongoing program of liaison with payers regarding these issues and are launching a new focused effort aimed at amelioration,” Muszynski said. “Where resolution is not forthcoming, the APA will commence an even more focused action with the problem payers and will consider all appropriate options as necessary.”

We need to get lawsuits against this illegal behavior blossoming in every state. The best thing we can do is to complain to the payers, our state psychiatric societies, our state insurance administrations, and our elected officials. Add your voice to the strength of the APA by sending it your evidence of improper or illegal insurance discrimination. See the box for more information.

—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on at drdavisATgmail.com, and  and on the Shrink Rap blog.