Introduction to the Special Section: Pediatric Psychologists' Experiences in Obtaining Reimbursement for the Use of Health and Behavior Codes

One of the most critical influences on the growth of the practice of psychology involves reimbursement for clinical services from a range of insurers. A hallmark of clinical practice in the field of pediatric psychology is a focus of psychological services on problems associated with the management of chronic health conditions (e.g., enhancing coping, pain management, treatment adherence, and promotion of health behaviors) rather than psychopathology. For this reason, traditional methods of billing that focus on identification of mental health diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association, 1994) and related procedure codes for assessment and interventions do not encompass the broad scope of practice of pediatric psychology. A related problem involves insurance company policy to reimburse mental health services through a separate mechanism or carve out apart from the basic medical benefit. For these reasons, the 2002 approval of the new health and behavior (H&B) assessment and intervention codes for inclusion in the current procedural terminology (CPT) system was heralded as an important development within clinical practice in pediatric psychology (Noll & Fischer, 2004) as well as for the field of clinical psychology in general. Within clinical psychology, the H&B codes are alive and well and used by psychologists to bill for Medicare services (394,162 outpatient visits in 2011) (R. Phelps, personal communication). It has now been 10 years since the approval of the H&B codes for use in a range of settings and time to summarize pediatric psychologists’ experiences in application of the codes (Tynan, Lutz Stehl, & Shroff Pendley, 2009). This special section of the Journal of Pediatric Psychology (JPP) was developed to provide a venue for practitioners from a range of settings to describe their collective experiences in application of and reimbursement for the H&B codes, to share strategies that have enhanced reimbursement, and consider approaches to advocate for policies to enhance effective use of the H&B codes. This introduction summarizes highlights from commentaries from a broad range of clinical programs that represent a cross-section of pediatric psychology services from various regions of the country, identifies implications, and clarifies next steps in future agenda for practice, advocacy, and research. Many pediatric psychology programs provide services to a broad range of populations with varied presenting problems and medical diagnoses. Lines, Tynan, and Angalet (2012) examined their experiences in billing with the H&B codes in a large pediatric hospital. The majority (62%) of claims were either partially or fully paid. The average rate of reimbursement was 46%. However, rate of reimbursement were quite variable depending on the insurance company: For example, commercial insurance reimbursed at 74% compared with instate Medicaid (59%) and out of state Medicaid, which reimbursed only 16% of the claims that were submitted. In addition, for reasons that were not entirely clear, interdivisional reimbursement rates were quite variable, including 37% for weight management, 44% for behavioral health, and 68% for rehabilitation. In another example from a general pediatric psychology service, Duke, Guion, Freeman, Wilson, and Harris (2012) reported their experiences in attempting to reverse denials of the codes. In their setting, the average reimbursement rate for services was only 26% of the total fees that were billed and included a 55% rate of denials. In an interesting head to head comparison of billing for a traditional mental health services code (90801) for an initial diagnostic evaluation with a comparable H&B assessment code (96150), the authors identified a lower denial rate (39%) for the mental health services versus the H&B codes (55.5%). The overall reimbursement rate for the mental health service code was somewhat lower (53.7%) than for the H&B codes (59%). However, because the mental health services code was billed at a higher rate, it resulted in greater financial recovery. Duke et al. (2012) suggest that disparity in payment for comparable services can create significant pressure for practitioners to use traditional mental health codes and diagnoses, even if they are not as good as a fit as H&B codes in maximizing reimbursement. Talmi and Fazio (2012) noted the importance of integrating behavioral health services in primary care and their experiences in using H&B codes to secure reimbursement for such services in such settings. The majority of visits billed the initial assessment code (96150), which was consistent with the focus of primary care psychological services, especially one-time assessment (triage visits) to address specific behavioral health concerns. Data that were gathered for Relative Value Units (RVUs) to assess clinical productivity (Seime & Manley, 1999) yielded a sufficient number of RVUs to cover 30% of a pediatric psychologist salary. Unfortunately, because the author’s hospital collected reimbursement data by encounter rather than billing code, it was not possible to obtain specific data for reimbursement rates. Talmi and Fazio (2012) also noted that the state (Colorado) in which they provided services has not reimbursed for any H&B codes because of a Medicaid rule that automatically rejects psychologists’ H&B coded bills as an unauthorized provider type when billed from primary care. The final commentary that focused on general pediatric psychological services described the process to secure Medicaid reimbursement for the H&B codes in one state (Oklahoma) and the results of 1 year’s experience with reimbursement (Woods and Gillaspy, 2012). This is an important experience given the absent or very limited reimbursement by Medicaid in many states as noted in other commentaries in this section. The process began by contacting the behavioral unit at the Oklahoma Health Care Authority (OHCA). A series of discussions about the nature and importance of the H&B codes to patient care and the fact that other insurance companies in the state were planning to reimburse for the codes convinced the OHCA of the importance of the codes. Although reimbursement for the codes was included in the state budget, it fell below funding priorities for several years. The authors noted that the initiation of a medical home (Stille et al., 2010) model for primary care that emphasized integration of behavioral health with medical care for children with chronic health conditions may have influenced the eventual decision to fund the reimbursement for the codes. Previously, the authors had worked with the OHCA and the state board to develop a process that allowed psychology interns and fellows to bill Medicaid for services based on the traditional mental health services codes. When the H&B codes were finally approved for use by psychologists, psychology trainees were also approved to bill for the codes, while under supervision of licensed psychologists. The reimbursement rates under Medicaid were largely consistent with that of Medicare but below that of private insurance and far below the estimated charges for the services. On the other hand, it is important to note frequent denials in Medicaid for H&B codes described by others (Brosig & Zahrt, 2006) were not noted by Woods and Gillaspy (2012). Pediatric psychology services are often provided in the context of multidisciplinary specialty programs. Several authors described use of the H&B codes in such programs. Claar, Kaczynski, Lyons, and Abel (2012) described their experiences in obtaining reimbursement based on the H&B codes in the context of a multidisciplinary program for the evaluation and treatment of pediatric headache. This program encountered significant variation in reimbursement depending on the specific insurance company as well as a decline in reimbursement from 51% to 31% over a 2-year period (2008–2010) owing to a change in the mix of payers that reflected a greater proportion of patients with policies that did not provide reimbursement for the codes. State Medicaid and one insurance company accounted for the lion’s share of poor reimbursement. Strategies that were successful in enhancing reimbursement for the H&B codes included detailed explanation of the specific services that were provided under the codes, clarification that these services cannot be provided by local in-network providers, and are closely tied to and consistent with the patient’s medical evaluation, diagnosis, and treatment. Other successful strategies included the development of relationships and consistent contacts between hospital billing staff and insurance company staff, developing a track record of services that were successfully authorized by specific companies, and highlighting these successes when attempting to obtain authorization for future patients. Brosig’s (2012) report concerned her experience in using the H&B codes in a pediatric cardiology setting. Frequent presenting problems in this included anxiety, depression, attention problems, learning problems, and cardiac transplant-related care. Payment rates for H&B codes ranged from 42% to 79% and contrasted with payments for mental health codes (24–34%). Brosig (2012) also found that payment rates had declined over 4 years (2007–2011) from 79% to 42%. The low Medicaid reimbursement rates (8–17%) were particularly striking. Strategies that facilitated reimbursement included education of insurance company staff about the need for and specific use of the codes with cardiology populations and having specialists with experience in billing for psychological services submit the bills to insurance companies. Sallinen and Woolford (2012) reported their experiences with the H&B codes in the context of a comprehensive weight management program. Psychologists provided initial assessments, reassessments, and behavioral interventions, including group and individual (Woolford, Sallinen, Clark, & Freed, 2011). Percentage collections provided by insurance companies increased from 21% to 26% over a 4-year period (2008–2011). Assessments yielded higher collection rates (35%) compared with interventions (23%). Individual interventions had a higher percentage of reimbursement (29–37%) compared with group (19%) or parent-based treatment (7%). State Medicaid (Michigan) did not reimburse for any services that were billed under the H&B codes. In order to increase reimbursement, the authors involved their hospital’s administration in presentations that they made to insurers. It is interesting and important to note that a survey conducted by the National Association of Children’s Hospitals and Related Institutions indicated that lack of reimbursement for services was the most frequently reported challenge for pediatric obesity programs (Eneli et al., 2011). This suggests that Sallinen and Woolford’s (2012) experience may be generalizable to other settings. The experiences describe in these commentaries underscore the importance of persistent strategic efforts by the leaders, administrative, and billing staff of pediatric psychology clinical services to secure reimbursement for H&B codes, as well as continued advocacy efforts at state and national levels to enhance reimbursement. Some of these strategies are summarized in this section. The commentaries in this section underscore the need for pediatric service and individual programs to support administrative staff’s time and anticipate and manage barriers for reimbursement for services provided under the H&B codes and to provide explanations of need and the impact of services, with detailed examples. In addition, detailed follow-up on claims that are not paid, building relationships with insurance company staff, and documentation of clinical need for a service that are reimbursed the codes, by health-care providers, are relevant and potentially effective strategies. Inconsistency of reimbursement for the H&B codes across a range of settings suggests that time and energies spent by faculty, administrators, and staff to secure reimbursement of H&B codes at local levels should be combined with collaborative advocacy at a state and national level. A maximally effective strategy will require a collaborative approach from state psychological associations, American Psychological Association (APA), and the Society of Pediatric Psychology (SPP). In order to be convinced that the H&R codes are important, policy makers may benefit from concrete, case-based examples of how psychological services have helped individual children and their families and showcase the potential negative consequences of limitations of reimbursement on the children’s health and well-being. For maximum impact, it will be important for professional organizations such as SPP to partner with parents and parent advocacy groups whose children have benefitted from psychological services that were reimbursed by the H&B codes may be especially convincing. Several of the commentaries provide excellent examples of advocacy efforts to secure reimbursement in specific settings that may have broader generalizability. For example, Lines et al. (2012) describe the importance of working with state of Delaware Medicaid to advocate for changes to open the H&B codes for reimbursement by pediatric psychologists. In addition, their work with local school districts to arrange for mental health services to be provided by a credentialed pediatric psychologist provider to Medicaid-enrolled students at two local elementary schools is an excellent example of creative advocacy. Another excellent example is Duke et al.’s (2012) developing partnership with Oregon state Medicaid program to provide intensive behavioral health services to adolescents and young adults whose hospitalization for chronic health problems such as diabetes were attributable to psychological problems that could be successfully managed and/or prevented by behavioral health interventions reimbursed by H&B codes. This partnership represents a potential “win–win” situation for both insurers and hospital for the following reasons: Private insurance companies (or Medicaid) who are responsible for covering the costs of hospitalizations for preventable conditions (e.g., diabetic ketoacidosis) can reduce costs. Hospitals stand to gain because hospitalized patients with problems that can be prevented by behavioral health “interventions” occupy beds that could be filled by patients with higher levels of acuity of medical problems that warrant greater reimbursement. Talmi and Fazio (2012) suggested a number of potentially useful strategies to enhance reimbursement of behavioral health services delivered by pediatric psychologists in primary care. These include: (a) developing capitated funding contracts with insurers to integrate qualified, experienced behavioral health practitioners in primary care (Cummings, O’Donohue & Ferguson, 2002); (b) restructuring models of service delivery in primary care to integrate services for medical and behavioral health problems under the structure of the medical home (Stille et al., 2010); and (c) developing innovative mechanisms to sustain and support behavioral health billing and reimbursement in primary care (e.g., creating access to behavioral health services for parental caregivers in pediatric settings (Golden & Fortuny, 2011). A final strategy that has promise to enhance reimbursement for the H&B codes that was not represented in these commentaries but is worth noting involves higher level negotiations by hospitals for insurance contracts that place all providers including psychologists on a level playing field. For example, at Cincinnati Children’s Hospital Medical Center (CCHMC), the Division of Payor Relations has negotiated contracts in which H&B codes are reimbursed at the same rate of reimbursement as other medical codes (Stark, 2007). This strategy puts pressure on insurers to find ways to fund behavioral health services if they want to develop or continue large contracts with the hospital. This has resulted in high rates (84%) of reimbursement rates of H&B codes, as well as mental health codes (80%) by private insurers (2011). On the other hand, this has not affected Medicaid reimbursement for the H&B codes in the state of Ohio which remains nonexistent based on state-level policy. It should also be noted that the generalizability of this negotiation strategy is limited by local market forces. For example, in order for a hospital to be successful with such an approach, they need to have a very favorable share of the health-care market in their region. This is true for CCHMC but is not the case with Rainbow Babies and Children’s Hospital in the same state, which faces stiff city-wide and regional competition (from the Cleveland Clinic and Akron Children’s Hospital), which was reflected in reimbursement rates of 40% for mental health codes for 2011. Taken together, the contributions to the special issue clearly indicate that while the H&B codes provide some reimbursement for psychological services, it is by no means sufficient to cover the costs of delivering psychological services in pediatric settings. These data can be taken as a cause for concern in that they reflect significant threats to the fiscal viability of pediatric psychology clinical services (at least as a stand-alone source of outcome) for all but programs with exceptional circumstances (e.g., excellent local market share and capacity to negotiate reimbursement rates). For this reason, the future economic potential of psychological services delivered in pediatric settings that are based on the H&B codes will continue to require concerted and persistent local and national advocacy. From a pragmatic standpoint, pediatric psychology service programs will need to leverage other sources of funding (e.g., from hospital or medical subspecialty budgets) in order to sustain support for service development (Drotar, 2004; Rae, 2004). This was already happening in many of the settings represented in these commentaries and is a testimony to the value that many pediatric hospitals and subspecialty programs place on the importance of services delivered by pediatric psychologists. However, this assumes that hospitals are doing sufficiently well in their economic bottom line to support such services. The commentaries that have been presented in this section have relevant implications for future directions in developing systematic strategies for tracking the use of and reimbursement for the H&B codes in a wide range of settings and for research that could enhance reimbursement by insurers. The findings reported in several of the commentaries indicated change over time and different reimbursement rates for H&B codes across different insurance companies and specialties who submit the claims. For this reason, it will be important for clinical service programs to develop ongoing methods to track reimbursement rates for the codes in order to monitor progress in reimbursement, to identify barriers that need to be addressed in order in enhance reimbursement, and strategies to surmount them. Such data can be used to summarize experiences with reimbursement with specific insurers, specific codes, or across specialty groups in order to identify gaps in reimbursement, set goals for advocacy efforts, and plan for the development of new services. A continuing and critical challenge for future research in pediatric psychology concerns the need for empirical demonstration that psychological services that are reimbursed by the H&B codes can ameliorate negative medical outcomes and health-care utilization and reduce health-care costs. There are any number of potential demonstration projects that could be potentially convincing to insurers (e.g., in costs related to visits to and diagnostic owing to effective pain management, of of and (e.g., in based on to medical Unfortunately, at this in to are no systematic that have the or of delivery of psychological services to pediatric populations that are reimbursed by the H&B codes. support of behavioral health services with adults et al., & including and report of the of intensive outpatient psychological service on health-care utilization in a large Unfortunately, of this work to demonstration of for the H&B codes in various For this reason, a critical future challenge for the field of pediatric psychology is to develop such for a range of pediatric chronic health problems and psychological services & 2009). 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