Tag: Mental health practice

Electronic Claim Filing for Secondary Insurance

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Our technical support and customer service staff regularly discuss questions our customers commonly ask. They often answers these questions in emails—repeatedly. For a long time, we have tried to answer some of these questions in documents to make it easier for our customers to succeed in their jobs. The Document Library page on our web site has always aimed to achieve that goal. This year, we implemented new and additional documents in a blog format on our web site as another way for our customers to get answers to their questions quickly.

Electronic claims filing is one of those areas where questions abound. No matter how many times we answer the same questions, we always need to come up with new and different ways to communicate information that is very familiar to us but not so apparent to our customers. This is the same kind of task psychotherapists and others who work with people in any capacity have to accomplish—coming up with different language and presentation of an idea so it can be heard and understood by the person being addressed.

Our lead technical support rep, Manon Faucher, recently wrote an article about how to file claims for secondary insurance carriers electronically. I have borrowed heavily from her article to address the issues that are crucial in successfully filing electronic claims for secondary insurance payers, assuming that the clearinghouse or site through which you send your electronic claims allows submission of secondaries and the payer to whom you are sending can receive secondary claims electronically.

In order to successfully submit secondary insurance claims, it is essential that you include the information about how the claim was adjudicated by the primary insurer. Doing so requires specific data in certain loops and segments of the 837P. If you are an SOS Software user, you should read Manon’s document. She created detailed instructions with screen shots for our product. If you use a different software product, you will need to find out from your vendor whether you can enter and they can report the necessary information to file the secondary claims.

  • Primary payer– You must be able to indicate the order of liability for payers. Make sure you have the Primary set as such for this claim.
  • Secondary payer– You must be able to designate this payer as Secondary for this claim. You must also be able to enter the “Amount received from other insurance”, information that would go in box 29 on the CMS 1500. This should go into the 2320 loop, segment AMT 02.
  • Verify the Claim Adjustment Reason (CAR) amount– If you have received an Electronic Remittance Advice (ERA) that automatically posted your payment from the Primary payer, you will need to determine that the total of the CARs matches the amount of the date of service Fee minus the payment from the primary insurance. Examples:

Denial – no payment by Primary

Fee for service $200
– Primary insurance did not pay for the service so $0 payment is entered for a Denial
CARs must equal the entire fee, $200.00

Partial Payment and Adjustment

Fee for service $200.00
– Primary insurance paid $120.00 and an adjustment of $30.00 was required from the payer
Amount of your CARs will have to equal to $80.00 ($200-$120)

The information from the CARs must be entered in the appropriate segment in the 2430 loop.

  • Adjudication or payment date: Make sure you have entered the payment date in the appropriate place so it will show up in loop 2330B segment DTP 03.
  • Generate and submit the secondary claim.

If your organization is not yet filing insurance claims electronically, it is certainly a service you should investigate. At some point in the future, it will certainly be required that all claims are filed electronically. In the meantime, it is a major convenience and financial savings for providers and organizations.

Maybe it is time for you to get rid of the paper!

Got any observations, opinions, reservations, cheers about filing claims electronically? Please share in the Comments section below. Thanks for reading!

 

 

 

Medicaid Shrinkage: Innovation or reaction?

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Just one year ago, after passage of the Affordable Care Act (ACA), The National Council highlighted the expansion of Medicaid that would occur as a result of the ACA. To meet the law’s requirements to provide insurance coverage to the working poor who are generally not insured through their employment, do not have access to insurance groups, and cannot afford individual coverage, the Medicaid program would need to expand to provide the legally required coverage.

In November, the American electorate hired new Congressional representatives who are dead set on rolling back what they call “entitlement” programs (Social Security, Medicare and Medicaid) and returning the Federal government to what they see as its proper role: funder of national security and protector of free markets (code words for defense and corporations). In this new/old world view, individual rights consist of the right to pursue happiness and to bear arms; communal responsibility for one another appears to be non-existent.

Where does that leave those with serious behavioral health issues and the people who treat them?

The National Council works to represent community behavioral health organizations and the people they serve. They view Medicare and Medicaid as crucial to the treatment and therefore to the survival of the seriously mentally ill since “Medicaid is the single largest source of funding for America’s public mental health system.” Since early March, The Council has reported regularly on the threatened slashing of the Medicaid and Medicare systems.

In early March, The Council reported that a group of governors testified about their need for greater “flexibility” in their Medicaid programs. This group especially wanted to be exempted from the maintenance of effort (MOE) requirement under ACA that prohibits the states from rolling back Medicaid eligibility. President Obama said he would support allowing states to opt out of the law’s requirements if they could guarantee an alternative method of providing universal coverage.

On April 4, Representative Paul Ryan (R-WI) released his committee’s plan for the 2012 budget that includes a dramatic restructuring and slashing of both Medicaid and Medicare. On April 7, the National Council released a fact sheet on the potential impact of the funding decreases promised by the budget blueprint. Under Congressman Ryan’s proposal, Medicaid would be converted to a block grant program beginning in 2013 and Medicare would be converted to a privatized voucher system starting in 2022. The House of Representatives voted to adopt this framework. While it is highly unlikely the Senate will accept the blueprint, they will need to come up with one of their own and then work to reconcile it with the House’s plan.

In a Health IT newsletter by Mercom Capital Group, it was reported that on April 14, 2011, The U.S. Department of Health and Human Services (HHS) “announced four initiatives to give states more flexibility to adopt innovative new practices and provide better, more coordinated care for people with Medicaid and Medicare while helping reduce costs for states and families.” In Florida which has been providing some Medicaid services through managed care contracts, the legislature is close to mandating managed care for the entire program in spite of poor reviews for the pilot programs. “At the workshop in Hollywood, a succession of doctors, care providers, advocates and Medicaid patients all had the same message: Managed care has been a disaster.”

As a small business owner who buys health insurance in the private marketplace for a very small group of employees, these proposals are extremely frightening. My health insurance premium at age 60 is already more than the proposed Medicare plan would pay once I become eligible at age 65, and my premiums will certainly not get any lower if I need to buy insurance in the private marketplace. If I, as a pretty healthy 60 year old, am so concerned about these changes to Medicare, I can only imagine the panicky reactions being experienced by those persons represented by the National Alliance on Mental Illness (NAMI) who are dependent upon Medicaid and Medicare to pay for their treatment.

How do you see these proposed changes impacting you and your organization? Do you agree with this method of limiting spending? What ideas do you have for controlling the growth of costs of Medicaid and Medicare? How do you propose that we proceed?

Please share your comments below.

Sleep Deprivation: The cost

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Two nights ago I woke up at 1:30 a.m. and did not fall back to sleep until 3:30 a.m. The room was too hot to sleep comfortably and I was awakened by a night sweat. I got up and cooled the room, but before I could fall back to sleep I was experiencing painful flushing caused by the niacin I take. Yikes! Today I am struggling with staying awake and trying to be productive.

According to surveys done between 1999 and 2004 by the National Sleep Foundation, 60% of adults report having difficulties sleeping a few nights a week. According to WebMD, some of the consequences of sleep deprivation can be:

  • Decreased performance and alertness
  • Memory and cognitive impairment
  • Stress on relationships
  • Poor quality of life
  • Occupational injury
  • Automobile injury

For many of us, irritability, poor decision making and decreased performance are the main problems. Yep, I have now started this article for the second time…my first try did not save properly.

According to sleep researchers, cognitive behavioral therapy can be as or more effective than the use of popular medications to solve sleep issues. Some of the recommendations for improved sleep include this list from the APA web site:

  • Keep a regular sleep/wake schedule
  • Don’t drink or eat caffeine four to six hours before bed and minimize daytime use
  • Don’t smoke, especially near bedtime or if you awake in the night
  • Avoid alcohol and heavy meals before sleep
  • Get regular exercise
  • Minimize noise, light and excessive hot and cold temperatures where you sleep
  • Develop a regular bed time and go to bed at the same time each night
  • Try and wake up without an alarm clock
  • Attempt to go to bed earlier every night for certain period; this will ensure that you’re getting enough sleep

I will definitely be heading to bed early tonight. I already do many of the other recommendations and usually sleep pretty well. Maybe that is why I am so discombobulated when my sleep is disturbed.

How often is sleep deprivation a problem for you? Has it become chronic insomnia? What do you do about it? How can we prevent this epidemic of sleep deprivation from undermining our lives?

Please share your experiences, your comments, your yawns 😉 below.

Integrating Behavioral Health into the Healthcare Home

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One of the many provisions included in the Patient Protection and Affordable Care Act (health care reform law) was the creation of pilot programs to integrate all health care services into a Health Home. The development of the ‘medical home‘ concept will be most important among those with complicated health concerns and in vulnerable populations. Those with significant health issues in addition to behavioral health disorders will be in special focus.

This attempt to integrate care will likely have major impacts on how behavioral health care services are provided to the seriously mentally ill and chemically dependent populations. The National Council has been actively involved in this movement and has received funds to found the Center for Integrated Health Solutions.

The National Council for Community Behavioral Healthcare has won a competitive cooperative agreement from the U.S. Department of Health and Human Services (HHS) to establish the Center for Integrated Health Solutions. The Center will address the comprehensive health needs of clients with mental illnesses and/or substance use disorders by improving the coordination of healthcare services in publicly funded community settings. The Center is funded jointly by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources Services Administration (HRSA).

In that role, on January 19, 2011, the National Council participated in an extremely informative webinar on current integration projects initiated by community behavioral health organizations. Each of the organizations that participated came to their ‘Health Home’ program in a different way and developed programs using different models. The presentation made clear that there are likely to be as many ways to accomplish the purpose of integrating health care for the most vulnerable populations as there are organizations that will provide that care. Even so, there are significant issues to be considered, challenges to be met, and goals to be accomplished for the establishment of a successful program.

A recording of this webinar is to be posted at http://coce.samhsa.gov/ at an indefinite date. Information about Co-Occurring Disorders Integration & Innovation can be obtained at contact@codimail.org. 

The hope that these programs can provide more effective health care at a lower cost is high. I am sure we will all be watching carefully to see how these and other initiatives progress.

I invite those  of you who have interest and experience with integrated care to share your perspectives. Your input will be valuable to your colleagues.

Implementing Evidence Based Practices

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Last week I attended the semiannual member meeting of the Software and Technology Vendor Association (SATVA), the trade association I have mentioned in the past. At lunch, I sat at a table with Don Hevey, the President/CEO of MHCA, described as “an alliance of select organizations that provide behavioral health services.” Their members are some of the largest community mental health centers in the country. We were talking about accountability and evidence based practices and Don mentioned a statistic from the American Medical Informatics Association and quoted in the American Psychological Association’s Monitor on Psychology

that it takes as long as 17 years for research findings to enter medical or mental health practice, and even then, only a fraction makes it in.

One of the others at the table (MHCA chair Tony Kopera, Ph.D.) indicated that part of the problem in mental health is that treatment protocols are often designed for and tested on those with a unitary diagnosis and relatively stable lives. This does not match the real world, community behavioral health center situation where many of the seriously mentally ill carry multiple diagnoses and may bounce from group home to the street to jail to hospital and back again.

The American Psychological Association has begun a science/practice collaboration for the purpose of creating treatment guidelines. Since the U.S. healthcare system has begun a significant focus on accountability, “providers need to show insurers and policymakers that their treatments provide good outcomes for patients” according to Katherine Nordal, Ph.D., executive director of APA’s Practice Directorate.

A treatment guideline won’t be a one-size-fits-all cookbook approach, she emphasized. Instead, a guideline will serve as a decision-making aid to help a practitioner decide the best possible course of care for a particular patient, combining clinical judgment, the best available research, and the patient’s individual characteristics and preferences. Longterm, clinical treatment guidelines can help improve patient care by identifying gaps in research and treatment where more work is needed to develop effective interventions.

I was interested to see that only one of the members of the APA treatment guidelines committee is a private practitioner; another member is with the VA. All others are academician/researchers. While this composition favors quality science, it runs the risk of overlooking real-world needs.

There are researchers who focus their attention on dissemination as well as implementation of the science that already exists. The APA has recently run multiple articles on this new field.

Until we figure out effective strategies to get evidence-based practices integrated so they can help people, they’re not much better than a nice publication,” says the National Institute of Mental Health’s David Chambers, DPhil, who directs the institute’s dissemination and implementation research arm.

Getting research into the real world, by Tori Deangelis, is an excellent examination of the resources and the challenges. DeAngelis quotes Dr. Gregory Aarons:

“Our job isn’t just to create new knowledge, it’s to improve the health-care delivery system,” he says. “Sometimes that means proceeding with the best available information and learning from experience, even though we’d prefer to wait for something a lot more definitive.”

While dissemination and implementation science are multidisciplinary by nature, psychologists with strong research backgrounds and an interest in systems change have much to contribute, adds psychologist Gregory Aarons, PhD, an implementation researcher and associate professor at the University of California, San Diego.

And in Evidence-based psychology in action, DeAngelis reports on an implementation of evidence-based practice in a community program utilizing a structured framework for this implementation.

The challenges of incorporating evidence-based practices (EBPs) into clinical practice has resulted in a whole field called implementation science. The National Implementation Research Network has as its goal “to close the gap between science and service by improving the science and practice of implementation in relation to evidence-based programs and practices. I can imagine this discipline becoming a major field as we attempt to control the costs of health care.

Resources abound. The US Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) maintains web resources aimed at dissemination of evidence-based practices, including those for mental health. The Substance Abuse & Mental Health Services Administration (SAMHSA) has long provided access to research and protocols for EBPs.

One of my biggest concerns about possible future mandates for the use of evidence-based practices is the challenge of getting treatments from paper to practice. Implementation science may help.

How is your organization proceding in adopting EBPs? Do you see a role for behavioral health specialists in implementation? What do you think about how we will get there? Please enter your comments below.