Consultation and Geropsychology: The Multi-dimensional Role of Psychologists in Long Term Care
Psychologists must accept assignment upon becoming Medicare providers. This means that the total amount that may be collected for a procedure is what Medicare allows for that procedure. It is not permissible to bill the patient for the difference between the Medicare allowable amount and the practitioner’s usual fee if it is higher than the allowable amount. Once enrolled with Medicare, a provider must bill Medicare for all clients with Medicare; the provider cannot arrange for private pay with any client who has Medicare.
It is necessary to apply for a provider number with Medicare, as well as apply for a National Provider Identifier (NPI).
Technically, the requirement for a written contractual arrangement lies with the agency or facility where a psychologist might work. The facility often must document to outside entities (e.g., State Department of Health) when a mental health practitioner is consulting at that location. However, a practitioner may see and bill these patients privately in that setting without a formal, written agreement. Nonetheless, it is good practice to outline in writing what the practitioner and what the facility agree to, including access to medical and financial records of patients referred, and patients’ right to privacy and confidentiality (and exceptions to these rights). Arrangements for paid consultation by the practitioner are included (e.g., staff training, participating in treatment team meetings or family councils, or working with unfunded patients).
When services are billed to Medicare, they must meet the criteria for medical necessity. Each Medicare Administrative Carrier publishes its own policies for every specialty, stipulating what services are authorized, what criteria must be met for each billed procedure, and what services are excluded from coverage. All initial clinical interviews, psychological testing, and ongoing progress notes must contain certain elements in order to meet the rigors of medical necessity. Mental health professionals are also required to communicate regularly with the patient’s attending physician, a practice that is easily complied with in nursing homes, but extra steps must be taken in residential and assisted living facilities because visits by the attending physician and chart reviews are not routine. More information is available on the GeroCentral Documentation page.
Upon referral, patients should undergo a complete diagnostic interview. Testing, including measures of cognitive, psychological, and neuropsychological functioning, may or may not be part of the initial clinical workup. However, in view of the complex presentation of symptoms, the interaction of medical and psychological conditions, and the fact that patient self-report often minimizes true underlying impairments in older adults, cognitive and psychological test measures are strongly recommended. Testing helps to document the presence and severity of psychological disturbances, decision making capacity, attitudes toward recovery, helps with treatment planning, and establishes a baseline to measure future progress or decline.
Individual, group, and family psychotherapy are all effective treatment modalities with this population. Many of the traditional professional services provided by psychologists in outpatient, residential and long term care settings address adjustment disorders. Long term care placement can produce psychological disorders due to a loss of independent functioning, separation from one’s home and family, and becoming dependent on caregivers. Depression and generalized anxiety symptoms are frequently in the clinical picture, and manifested typically by withdrawal and isolation, eating and sleeping problems, non-adherence to treatment plans, and disruptive behaviors. Also, behavior problems often accompany the mental decline that accompanies dementia. The theme of death and dying must be included in the purview of the consulting psychologist, as well as counseling and support for the patient’s family, and psychoeducation on a variety of clinical issues.
If a patient is inappropriate for psychotherapy services, developing and implementing behavioral strategies (beyond the actual assessment and written plan) without patient interaction and without engagement in a psychotherapeutic process is not billable. And, conferencing with staff about behavioral interventions also is not billable.
The health and behavior CPT codes allow psychologists to treat patients who do not have a psychiatric disorder or diagnosis. Assessment and interventions are based on the medical diagnosis, the co-morbid or underlying psychological factors affecting or impacted by the medical conditions, and problems in coping with or managing the medical condition.
Most insurance plans, including Medicare, do not cover staff consultation, case conferences, supervision of behavioral interventions, or staff training.
Ideally, the mental health practitioner is perceived as a member of the interdisciplinary treatment team. The more that the team members confer with each other, and discuss treatment plans based on the patient’s unique strengths and weaknesses, as well as the constellation of medical, social, and psychological problems that are present, the more the patient will gain from this collaborative interaction. Attendance at nurses’ care plan meetings and other events (e.g., psychotropic management) fosters an integrated care model.
Consultation in any long term care setting requires the psychology practitioner to communicate in ways that the medical team understands. The team members want answers to quickly diagnose and fix problems. They need concise information and updates. Thus, this is part of our changing role as we become part of this interdisciplinary team, and communicate more effectively with medical professionals.
Staff inservices are always highly desired in long term care settings, and the most sought after topics include managing problem behaviors, communicating with confused residents, stress management, ethics and end of life issues, and family interactions.
Medicare Part B covers mental health services. Initial diagnostic interviews and psychological testing are paid at 80% of the Medicare allowable (i.e., the maximum amount allowed for a procedure). All psychotherapy services and health and behavior procedures are now paid at 80%. The remaining co-payment may be picked up by a Medi-gap policy (i.e., secondary payer), by Medicaid, or by the patient. If Medicaid is part of the payer mix, the practitioner may not bill the Medicaid patient directly for the unpaid balance.
While many practitioners manage their own billing, a mental health practitioner can arrange for private billing for services. Medical billers typically charge 8- 10% of collections and can be found locally and on the internet. When considering an outside biller’s responsibilities, it is important to ask about billing secondary payers, verifying eligibility, assisting with enrollment in third party plans, and following up on denials and disallowed services. Arrangements can be made with practice management organizations (i.e., medical services organizations, or MSOs) that provide the practice locations, medical records, billing, and clinical and administrative support, all of which allow the practitioner to do his or her clinical work without managing the details of operating and building a long term care practice.
Lastly, a practitioner should always be prepared for possible Medicare reviews and audits. These may occur up to seven years following the date of services, and may occur pre-payment or post-payment. The practitioner must be able to justify that each service that was billed met medical necessity criteria, and was in full compliance with Medicare regulations. Avoiding exposure for “unnecessary” services and the recoupment of over-payments from Medicare requires expertise, diligence, and a healthy respect for the “honor system” under which Medicare works.
Written by Joseph Casciani, PhD, and President of CoHealth and Concept Healthcare
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