The Practice of Psychology in Medical Settings: Financially Sustainable Models

Abstract

Psychological services are safe, effective and economical treatments for multitude of medical conditions. For a variety of contractual and procedural reasons though, when psychological services are performed within a medical setting, obtaining payer reimbursement is often problematic. Because of this, many settings make no attempt to seek reimbursement for these services. This is not a sustainable in the long run though, as it leaves the psychology profession with no economic value to the institution. However, an examination of medical business methods reveals a number of financially sustainable models for the practice of psychology.

I’ve got all the money I’ll ever need, if I die by four o’clock.

—Henny Youngman

Appendix 1

American Psychological Association (APA) Sample Language for Letters to Private Insurance Carriers Regarding Coverage of Health and Behavior Services

It has been brought to our attention that your company is not currently reimbursing psychologists for services provided under the Current Procedural Terminology (CPT) health and behavior assessment and intervention codes. We would like to take this opportunity to enhance your understanding of the new codes and to discuss the value and effectiveness of health and behavior services.

An Overview of the Health and Behavior Assessment and Intervention Codes

The health and behavior codes were developed to provide psychologists and other health care providers with a way to accurately capture services that focus on the biopsychosocial factors affecting physical health problems. Examples of the physical health issues that psychologists might address under the new codes include patient adherence to medical treatment, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to physical illness. In almost all cases, a physician will already have diagnosed the patient’s physical health problem before a psychologist sees the patient.

The assessment codes apply to services that identify biopsychosocial factors important to the treatment or management of physical health problems. The intervention codes reflect services used to modify biopsychosocial factors affecting a patient’s physiological functioning, health, and well-being. The codes are published in the CPT manual issued by the American Medical Association (AMA) as follows:

96150:

The initial assessment of the patient to determine the biological, psychological, and social factors affecting the patient’s physical health and any treatment problems

96151:

A re-assessment to evaluate the patient’s condition and determine the need for further treatment

96152:

Intervention services provided to an individual to modify the psychological, behavioral, cognitive, and social factors affecting the patient’s physical health and well-being

96153:

Intervention service provided to a group

96154:

Intervention service provided to a family with the patient present

96155:

The intervention service provided to a family without the patient present

As you are likely aware, developing new CPT codes is a stringent process subject to review by various AMA-coding committees. APA worked closely with the AMA on the creation of the health and behavior codes because psychologists are among the leading health care providers whose training prepares them to furnish these types of services. In 2000, assisted by the National Association of Social Workers, APA conducted a survey to determine appropriate values for the codes and made recommendations to the AMA’s Relative Value Update Committee (RUC) concerning values for the new codes. In 2001, the RUC recommended that the Centers for Medicare and Medicaid Services (CMS) adopt the values forwarded by the RUC.

CMS accepted the RUC’s recommendation and included the codes and their relative values in the 2002 Physician Fee Schedule published in the November 1, 2001 Federal Register (66 FR 55245, 55463, 55499). At that time, CMS designated the codes as “active,” meaning the codes would be reimbursable effective January 1, 2002 so long as Medicare covered them. Subsequently, CMS determined that Medicare would cover the health and behavior codes with the exception of code 96155 (family intervention without the patient present). CMS excluded code 96155 from coverage because Medicare pays only for services provided directly to Medicare beneficiaries.

Psychologists’ Role in Addressing Physical Health Problems Through the Use of Behavioral Assessments and Interventions

According to the AMA’s CPT Changes 2002 manual, the new codes may be utilized by pediatricians, family physicians, internists, psychiatrists, psychologists, advanced practice nurses, clinical social workers, and other health care professionals within their scope of practice who have specialty or subspecialty training in health and behavior assessment/intervention procedures. However, physicians performing these services are directed to use the Evaluation and Management or Preventive Medicine services codes.

In order for a psychologist to provide both health and behavior assessment and intervention services to a Medicare beneficiary, he or she must be a “clinical psychologist” as defined in Medicare.⁴ This means the psychologist has a doctoral degree in psychology and is licensed or certified by the State in which he or she practices to provide diagnostic, assessment, preventive, and therapeutic services directly to individuals.

As noted earlier, the new health and behavior codes are intended to be used with patients who have a physical health, not a mental health, problem. Although more typically recognized for their work involving mental health, psychologists also use their skills and abilities to treat patients suffering from physical health problems. When treating a patient for a mental health diagnosis, a psychologist would use the appropriate psychotherapy code, not one of the health and behavior codes.

We trust this letter explains the purpose for which the health and behavior codes were developed and clarifies that psychologists, along with certain other health care professionals, are authorized to provide services under the codes. We look forward to hearing that your company has decided to provide coverage of health and behavior services by psychologists.