DBs Report Members Dropping Managed Care

Below are some of the specific responses from the DBs.

Georgia Psychiatric Physicians Association: All companies have the occasional “system meltdown,” which often seems to account for slow reimbursements; one company is hard to reach on the phone. Many MCOs have determined that preauthorization for CPT code 90805 and 90862 is interchangeable. Most psychiatrists who primarily do traditional psychotherapy have opted out of the insurance plans.

South Eastern Massachusetts Psychiatric Society: Reimbursement rates have been generally “flat.” PBMs are a problem, especially with Medicaid. There are no noteworthy differences among the MBHOs in terms of quality—whether carved out or carved in. About one-third of members have opted out of all managed care plans and do not accept new patients covered by them.

Michigan Psychiatric Society: Some companies are negotiating reimbursement rates, and some have improved their relations with psychiatrists. Most PBM issues relate to the Medicaid formulary.

Minnesota Psychiatric Society: Managed care problems have “leveled off” with more integration of services and more dialogue. Patient access, however, is a problem, which all parties are addressing. Psychiatrists are increasingly opting out of managed care networks, especially those who practice psychotherapy. PBMs are requiring arbitrary preauthorizations. Administrative demands continue to rise, and late payments are common. Most psychiatrists do medication evaluations, for example, CPT code 90862, because it is too difficult to get preauthorization for CPT code 90807.

West Hudson Psychiatric Society in New York: The number of psychiatrists accepting patients covered by managed care is rapidly dwindling. There is a significant problem with access to services and “phantom” provider lists. PBMs are increasing the amount of time spent on time psychiatrists spend on prescribing medications.

Oregon Psychiatric Association: There are fewer requirements for preauthorizations.

Texas Society of Psychiatric Physicians: Many claims are not paid on time. No company is accepting E&M codes. PBMs are taking more and more of psychiatrists’ time, and some are altering the physician’s choices about first-line treatment. Most members are taking new patients covered by managed care. There are differences in the MBHOs, that is, some have physician-friendly Web sites, while others are hard to contact. Only one MCO makes follow-up calls about quality issues. In general, the carveins have better integration of care; the carveouts are less efficient and more costly. Employers offer widely different mental health coverage: oil companies, railroads, high tech firms, and one major airline are at the high end of coverage.

Psychiatric Society of Virginia: Managed care has increased its penetration in some areas, but several members believe there are fewer hassles, especially for medication management. Still, integrated treatment is difficult to obtain. Medicaid’s paperwork and low reimbursement rates are particularly problematic. Inpatient lengths of stay are troublesome, as well as authorization procedures for continuing services. Reimbursement rates are extremely low, which local MCOs have promised to remedy. Payment of claims is slow. One company dropped preauthorization for CPT codes 90862 and 90805, which are reimbursed at the same rate. One company is allowing the use of E&M codes, but has a “fixed reimbursement rate” at the CPT code 99241 level regardless of the level of service provided. PBMs are becoming an increasing problem: newer medications require higher copays, there’s a tendency to deny payment on “administrative” (as opposed to clinical) grounds so there is no appeal option, and reimbursement for doses above amounts specified in the PDR are difficult to obtain. With the exception of psychiatrists in areas such as Northern Virginia, most members are taking new patients covered by managed care. Administrative work is increasing. The state managed Medicaid program was deemed “virtually unworkable.” Employers who value their employees more as individuals rather than as interchangeable “widgets” tend to provide better coverage, especially for companies that make a large investment in education or training of employees.

West Virginia Psychiatric Association: Reimbursement rates are going down, and payment of claims varies. Some individuals are contemplating not accepting Medicaid-insured patients because of the low reimbursement rates and increased management of the plan. PBMs have increased the time psychiatrists spend on prescribing and, in many cases, the formulary has altered choices about first-line treatment. Most members are taking new patients covered by managed care, but some physicians will not accept patients covered by certain plans. Employers are providing widely different coverage, although none of the coverage would be rated “high quality.”

“We suspected that there were wide variations in the practices of MBHOs throughout the country,” Lurie said, “and there are; but we were surprised at how many of the problems are pervasive, for example, poor access to services, hassles, and low and slow-to-arrive reimbursements.”

Managed care has come a long way since the Committee on Managed Care surveyed the DBs in 1994. At that time psychiatrists were concerned about getting onto managed care panels, being terminated from managed care networks, and passing any willing physician legislation. The committee established the Managed Care Help Line to monitor these problems and assist members.

“We encourage the DBs and SAs to take advantage of using the Help Line,” said Lurie, “so that the committee can correct problems reported.” For example, Lurie noted the committee’s work on halting Oxford Health Plans’ efforts to audit member records and collect past reimbursements (Psychiatric News, January 2). The committee is routinely in contact with medical directors in MCOs and MBHOs and encourages APA to seek appropriate legislation when necessary.

Lurie emphasized that individual psychiatrists may be able to negotiate higher reimbursement rates. “Some companies are more responsive than others,” he said, “but MCOs rarely initiate higher reimbursement rates themselves.”

APA members and DBs/SAs may reach the Managed Care Help Line at (800) 343-4671. The Committee on Managed Care welcomes additional reports from the DBs/SAs. They may be e-mailed to [email protected].