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The Physician Quality Reporting System (PQRS) is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. Sponsored by the Centers for Medicare & Medicaid Services (CMS), PQRS reporting allows the clinician to obtain small bonuses – up to 0.5% of total Medicare allowed charges – and, starting in 2015 based on 2013 reporting, to avoid up to 1.5% of total Medicare allowed charges penalty.
The sources for the most current information include the PQRS pages at CMS (Centers for Medicare & Medicaid Services) and the PQRS pages at the American Medical Association website.
Also, the QualityNet Help Desk provides direct telephone or email help on PQRS and is available Monday-Friday at (866) 288-8912 or via
The information that follows is meant only as a guide. Refer to the above resources for the most authoritative information.
CMS has issued this list of eligible professionals who can report PQRS.
No. Registration is not required to participate in PQRS.
PQRS Measures in 2014:
In 2014, providers wishing to participate in PQRS will need to continue doing claims-based reporting until ICANotes is certified for 2014 Meaningful Use. The measures eligible for claims-based reporting have changed from 2013, and a list of those most relevant to behavioral health practitioners will be posted here shortly.
Measures for 2014 must be selected from at least 3 different domains as defined by CMS, and reporting is for a 12-month period. Some of the measures from 2013 are no longer eligible for claims-based reporting.
There are 3 ways to report:
After submitting a claim with PQRS code(s) added, you will receive a notification with the N365 denial code which is an indication that the PQRS codes have been received into the National Claims Registry. You will get a notice with this code each time you submit a claim form with a PQRS code(s). This indicates that a PQRS related claim has been received. It is not the final word on whether or not you qualify for the incentive.
If you are a mental health professional working in private or group practice, you have your work cut out for you. Serving your clients well, and finding the time to handle all of the administrative tasks of your practice can become quite stressful.
Mental health professionals have billing needs that differ from other medical professionals. It is commonplace for many types of medical doctors to have large office staffs, with many administrators handling the billing and claims.
However, many (and perhaps even most) mental health practices run on much thinner financial margins than their “medical” counterparts, and therefore the burden of mental health billing often falls on the counselor, or a small office staff. Perhaps because of this, sadly, many practices collect less than 85% of the money they are owed from insurance companies.
You can do much better than this! With some perseverance, and a strong working knowledge of billing, you can expect to collect 96%, to as high as 99% of your claims. Here are some quick questions and answers that will save you time and money.
To Bill, or Not to Bill
Mental health billing is not always an easy or straightforward process. However, with patience, perseverance, and maybe even a little training from someone who has done it before, you can tackle your practice’s medical billing.
Alternatively, mental health billing can be outsourced to a professional billing company. Some counselors find that they are better off delegating billing tasks, and offsetting the costs by spending the time that they would have spent billing insurance claims seeing a few more clients. The choice is yours!
Organizations that advocate for mental and behavioral health, groups that long complained they were treated as second-class providers, have applauded the federal laws. “Some people have paid for mental health out of pocket because they didn’t have mental health insurance,” said Dr. Katherine Nordal, executive director for professional practice at the American Psychological Association. “I think now they’ll expect their providers to accept insurance.”
But inclusion into the mainstream has come with some unhappy caveats: Cash was simple. Patients used to paying $150 in cash for a therapy session will, with some limitations, be covered by their health plan.
That means many therapists will have to figure out innumerable insurance plans and byzantine billing codes for the first time. “A lot of people come to me and they’re almost falling apart,” said Griswold who wrote a book called, “Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – and Whether You Should.” “It’s almost like a therapy session with these therapists. Seriously! I had a woman cry on my couch. She was like, ‘I don’t know how to do this!’”
Therapists who already accept insurance typically take a big pay cut since insurers negotiate fees that are about half of what they charge for cash visits. Blue Shield of California, for example, recently asked Griswold to accept a 10- to 30-percent discount off of her already discounted rate for patients who will buy health plans through the new online insurance marketplace. She refused and then wrote about the negotiations in her popular newsletter. “I put out in my newsletter, ‘Do you even know what you signed?’ And people wrote back, ‘Oh my God, I had no idea!’”
In many ways, therapists are encountering what medical doctors have complained about for years: the confusing and confounding – some say hostile – insurance bureaucracy that providers must tangle with in order to get paid. Therapists are expected to invest in expensive electronic billing software and electronic health records and comply with a tome of regulations.
“Just keeping up with all of that quite frankly is exhausting,” said Erica Savino Moffatt, a psychiatric nurse practitioner in Boston. “If you’re Jane Therapist hanging her shingle down the office from her home, it used to be the benefit was a better work-life balance and control over your immediate work environment. But a lot of that is lost in trying to track all of these logistics.”
The dizzying complexity of running a practice has meant more therapists are taking down their shingles, and consolidating with each other to share the burden, executives at national mental groups say. Or they are joining large medical groups in which mental health services are part of a continuum of care.
The changes are part of a remaking of a system that has long treated the mind as separate from the body. “If you look how many airlines there are today versus 10 years ago; if you look at hardware stores versus Home Depot and Lowe’s; it’s really a monopoly economy,” said Linda Rosenberg, president of the National Council for Behavioral Health. “And I think solo practitioners are going to be employees of big systems.”
In Tacoma, Wash., Dr. Barry Anton works as a clinical psychologist at Rainier Associates, an outpatient mental health clinic staffed by 17 therapists. Solo practitioners “might find it difficult to succeed in the new environment because the health care delivery system is evolving,” Anton said.
As insurance companies look to provide mental health care on a large scale, clinics like Rainier Associates are attractive partners. “It’s been very convenient and efficient for the insurance company to work with a bigger group,” said Anton. “We only have one tax ID number; we take care of all the credentialing; we take care of all the billing. They cut one check. It’s just more efficient for them.”
Psychologists, psychiatrists and other therapists in larger groups gain bargaining power as well and can demand higher reimbursement rates from insurance companies. “For those mental health practitioners who can develop group practices where they can provide a full range of services – from psychotherapy to family therapy to marriage therapy to medication management – they are going to be in a much better position to negotiate not only with commercial carriers but also with the federal government,” said Nordal of the American Psychological Association.
In addition to super-sizing mental health practices, mental health providers are beginning to play a bigger role at primary care clinics.
Savino Moffatt is a newly minted graduate who, instead of starting her own practice, saw where the future was headed: She works as a psychiatric nurse practitioner at a large clinic in Boston that is well positioned for the era of integrated medicine. She sits alongside internists and pediatricians who previously didn’t know where to turn to for psychological help with their patients. Now, Savino Moffit is just down the hall. “Once you say, ‘Hey, I’m here! I do psychiatry.’ And they kind of look at you like, ‘Oh thank goodness! I have a patient and I’m so worried!’”
Savino Moffit says she can identify mental health conditions like depression that might be masquerading as physical symptoms and which allows physicians to better serve their patients. It also can save the clinic from ordering costly and unnecessary tests, an important consideration for large medical groups that receive a set amount of money each month to cover all the needs of their patients.
Mental health experts say setting up these new business models will take time; that it’s a marathon, not a sprint. Barbara Griswold, sitting in her therapist’s chair at her office in San Jose, says that’s about the right speed. “I tend to think therapists overreact about change. We’re not really good with change, which is funny because we help people with change.”
In the corporate world of American health care, with its consolidating hospital chains and doctors’ groups, psychologists and other mental health therapists are still mostly Mom-and-Pop shops; they’ve built solo practices, hanging their own shingles, not unlike Lucy in the Peanuts gang: “Psychiatric Help 5¢, The Doctor Is In.”
But that business model is shifting from solo practices toward large medical groups, say mental health experts. The shift is propelled by the Affordable Care Act, which mandates mental health benefits in insurance coverage, and the 2008 mental health parity law, which requires private and public insurers to cover mental health needs just as they do medical conditions by charging similar co-pays, for example.
“It’s a big change for us,” said Barbara Griswold, a marriage and family therapist in San Jose, Calif. “I spent all of my life setting up this practice where I choose my clients, I choose my hours.”
In just the last few months, Griswold has weighed a new contract with a giant health insurer, warned other therapists to watch what they’re signing in payment negotiations and considered the extinction of her own solo practice. “The idea of me moving into an interdisciplinary practice where somebody else is taking care of my billing, and someone is choosing my clients for me —there is a loss of autonomy that a lot of therapists are frightened about,” Griswold said.
Under President Barack Obama's health care law, which aimed to end health insurance discrimination for mental health services, an estimated 62 million patients now have better coverage. But a new report from the National Alliance on Mental Illness shows the policies still have a long way to go before they can make a difference in the lives of people living with mental illness.
From lack of access to psychiatrists to expensive costs for medications, the study reveals a variety of issues that NAMI says show insurance companies are falling short in coverage of mental health and substance abuse disorders, collectively referred to as "behavioral health" services.
[The Mental Health Parity Act, enacted in 2008, requires mental health benefits in some employer-sponsored plans be provided on the same terms of other medical care. When the Affordable Care Act became law in 2010, coverage was expanded to private health plans sold in state and federal marketplaces, where Americans can buy tax-subsidized plans based on their income. Mental health care is one of 10 required benefits, just like maternity care and vaccines, for all plans sold.
But the definition of "parity" is murky at best.
"We're all still trying to understand what it means," says Sita Diehl NAMI’s director of state policy and advocacy. "Gray areas remain, and we are finding them out as we go along."
Caroline Pearson, vice president for health reform at Avalere Health, admits the lack of a clear definition made the analyzing the NAMI study difficult. "We tried to adhere to the current mental health parity regulations, but they are not sufficiently specific to be able to make a really clear judgement," she says.
Part of the problem is that many psychiatrists do no accept insurance, charging patients out-of-pocket for care instead. Pearson also points out that benefits listed on a plan may not be clear. "There's a whole array of nuance," she says. For instance, a plan might list that it covers in-patient psychiatric care but doesn't specify the kind of facility in which that care may take place.
For the report, NAMI surveyed 2,720 customers and analysed 84 health insurance plans – both employer-provided plans and ones purchased through the marketplaces – in 15 states.
The project was funded by pharmaceutical companies Eli Lilly and Co., Genentech, Otsuka Pharmaceutical and an anonymous NAMI donor.
In response to the report, Clare Krusing, the spokeswoman for America's Health Insurance plans, the trade association for the industry, said in a statement that health plans had a unique understanding of the challenges patients and their families face when it comes to managing behavioral health conditions. "The goal is to ensure patients have access to the right care at the right time and in the right setting,” she said.
The Substance Abuse and Mental Health Services Administration found in a 2013 report that 9.6 million adults reported having a serious mental illness, such as major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder, panic disorder, post traumatic stress disorder or borderline personality disorder. People with mental illness require an individualized treatment plan that could require medications, therapy and participation in peer support groups.
"Any barrier that stands in the way is cause for saying ‘never mind,’ and your life falls apart," Diehl says.
Untreated mental illness can lead to unemployment or homelessness, and people may turn to substance abuse to self-medicate, which can make symptoms worse. Some turn to suicide, and many end up in prison instead of receiving care.
Nearly a third of NAMI survey respondents reported insurance companies denied authorization for mental health and substance abuse care because the insurance companies deemed the care not medically necessary. "In the absence of uniform criteria, insurers have adopted their own standards and have often not been forthcoming about informing beneficiaries about these standards," authors of the report wrote.
The report follows a series of bad news for mental health advocates. NAMI found in a December report that funding for behavioral health services still lags at the federal and state level.
Also, despite intended expanded access under the law, a report from U.S. News in October showed that Americans with mental health issues or substance use disorders aren't lining up for care. It found some Americans didn't know know about the new provisions, while others were barred by loopholes in the law or fell into a coverage gap because their state didn't expand Medicaid for low-income people and they could not afford to buy private health insurance. People who don't have coverage are more likely to put off medical care or to skip it altogether.
"With mental illness, that’s the beginning of a slippery slope, and your life can come completely apart," Diehl says. "It makes sense to pay at the front end and make it affordable."
But even with health care coverage there remain gaps in the care a patient can access, the report shows. Recent projections from the Congressional Budget Office, the nonpartisan score-keeping agency, revealed that premiums on average are significantly lower for people purchasing health insurance through the marketplaces than originally anticipated. This was touted by the White House as good news, but authors of the CBOreport say the lower premiums may be due to beneficiaries selecting lower-cost plans – ones that have limited provider networks. This means their insurance may not cover the doctors, hospitals, procedures or even individual members of a surgical team, potentially heaping costs on consumers.
"The networks looks good on paper, but when you actually try to find a provider you end up with a lot of roadblocks," Diehl says. "Narrow networks are an egregious problem."
There also aren't enough mental health providers in the networks, the report finds. Participants in the survey said it was most difficult for them to find a therapist or a counselor, and only slightly less difficult to find a psychiatrist. According to the federal government’s Substance Abuse and Mental Health Services Administration, 55 percent of counties do not have a practicing psychiatrist, psychologist or social worker. Rural counties, in particular, are affected by the shortage.
Even if the medical provider is included in a health care network, he or she may not be available. In January 2015, the Mental Health Association of Maryland published a study that revealed only 14 percent of psychiatrists listed in the qualified health plans in the Maryland marketplace were actually accepting new patients and available for an appointment within 45 days – the suggested wait time.
Findings also showed that customers had a difficult time paying for medications, and that certain medications, like some antipsychotics, were not covered at all or only available with high out-of-pocket costs. For marketplace plans, denials were nearly twice the rate for other medical care.
"[The Department of Health and Human Services] needs to regulate health plans and costs so consumers don’t end up sharing this much of the cost," Diehl says. "Without the regulation, Congress should work to decrease out of pocket costs."
NAMI made a variety of other recommendations in its report, from publishing more information about health plans' specific coverage to establishing easily accessible procedures for filing complaints.
"It’s an improvement in terms of access, but it’s not the improvement we had hoped for in terms of coverage yet," Diehl says. "We have more work to do to achieve parity."
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