August 21st, 2013

Reimbursement, client eligibility issues cause confusion

Issues regarding reimbursement have long plagued psychologists. Recently, some Massachusetts providers have become frustrated over the complex rules regarding “crossover” payments and client eligibility.

According to James Leffert, Ed.D., co-chair, advocacy committee of the Massachusetts Psychological Association (MPA), reimbursement issues present “a mystery wrapped in an enigma.” He cites the complicated formula for receiving payment for clients with Medicare, Medicaid, private insurance or some combination of the three payers. Additionally, he reports confusion over and concern for clients in the Qualified Medicare Beneficiary (QMB) program.

The federally-funded Qualified Medicare Beneficiary Program, which is run through Medicaid, is an income-based benefit for the beneficiary and pays for Medicare Part A and B premiums, deductibles, coinsurance and copayments, according to Courtney Porter Jenkins, regional public affairs specialist in the Office of the Regional Administrator at the Centers for Medicare & Medicaid Services (CMS) in Boston.

To qualify for QMB status, an individual’s monthly income is limited to $978; a married couple cannot exceed a monthly income of $1,313. Jenkins adds, “There is no such thing as a QMB provider, but you do have to be a Medicare provider or Medicare won’t pay for the visits.”

To become a Medicare provider, a psychologist need enroll only once, but is subject to a ‘revalidation enrollment process’ every five years. Jenkins says, “There is no fee for individual providers, but there is a fee of $532 for institutions, hospitals, home health agencies and companies that supply durable medical equipment, prosthetics, orthotics and supplies.”

Patients might lose their QMB status if they fail to reapply or no longer fall within the income limits of the program, Jenkins explains. “If the patient lost that status, they would no longer be on Medicaid so Medicare wouldn’t cover them because they don’t have Part B insurance coverage. The patient can’t get outpatient services if Medicaid is not covering Part B.”

Leffert points out that before he accepts clients, he verifies their QMB eligibility through the Executive Office of Health and Human Services online database. “As a therapist, I’m working to help people be more productive, re-enter society, improve their quality of life and contributions to the larger community. When these clients are on Medicare and MassHealth, they are earning zero dollars,” he says. “When they start doing better, they might get a job and begin earning a little money, so they fall out of the QMB category. I’m excluding non-QMB clients because it doesn’t pay for me to serve them,” he says, noting that Medicare has been “dramatically and precipitously cutting” what it pays psychologists and noted that he received $102 per session in 1997 but is currently getting $80.

Psychologists who have questions regarding reimbursement report inordinately long wait times to speak with MassHealth representatives. In response, Chris Counihan, director, behavioral health unit in the Massachusetts Office of Medicaid (MassHealth) explains that the legislature provides limited funding for the department. “The customer service team is therefore limited,” he says. “We’ve made great strides in reducing wait times, but people call with a wide range of questions and we don’t have subject matter experts. But we do have a library, which may not always be up-to-date. There are lapses between policy changes.”

In January 2014, MassHealth will tie into a national database that will streamline the process for enrolling and checking eligibility and eliminate paper applications, according to Counihan. “This should free up the customer service team to deal with other issues. MassHealth will go out to trade associations to help them understand the changes regarding enrollment. We want to do all we can to enable our providers to give good services.”


Clarifying crossover payments

According to Chris Counihan, director, behavioral health unit in the Massachusetts Office of Medicaid, MassHealth serves 110,000 medically complex individuals. When a psychologist provides services for one of these “dual eligibles” – those who have both Medicare and Medicaid (MassHealth) – the billing goes first to Medicare, which pays a portion of the bill. Medicaid is considered the second payer and covers the remainder of the bill or the “crossover.”

Counihan emphasizes that Medicaid will only pay for clients who have QMB status. He advises providers to check the eligibility status of clients regularly since vagaries occur frequently.

By Phyllis Hanlon

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