Patients

UPDATES REGARDING PAYMENTS/INSURANCE PLANS FROM Dr. SEPAH

Background

There are roughly 3500 psychiatrists in the state of CA for a pop of 39 million. Of those, roughly 20% are employed in the county, state, federal correctional or state hospital systems of which I was for five yrs.  Now as part of the  2700 or so left to serve the community, I am part of a fraction—only 20%—who are paneled with insurance plans and part of an even smaller percentage that accepts Medicare.

There is a very simple reason for this which has to do with psychiatrists being demoted to   “behavioral health providers” for two decades and as such now such being the physicians who have to panel TWICE to participate on insurance panels: once as ‘behavioral health providers’—a made-up term used to classify psychiatrists as lesser physicians and thus declare psychiatry not necessary medical care but something contributed, called behavioral health, which was an ‘optional add on’ until the ACA.   Now we have the right to panel fully as physicians, once one the  “medical panel but also still must panel first as ‘behavioral health providers’.   We are reimbursed 21% less than PCP’s for the same time-based CPT codes and 17% less than other specialists based on the last two Millman reports. This has to do with the two layers of paneling, the lack of transparency this introduces in combination with a lack of enforcement of the MH parity laws of 2013. Only seven states have passed laws to actually enforce these laws—CA is not one of them. For those who have rec’d TMS—you have seen that each plan has established an arbitrary threshold, not one based on the FDA clearance, but rather whatever that plan wants. That’s not the case with treating other diseases with high mortality rates as severe depression certainly.  Suicide is the 10th leading cause of death in the US, now the #1 cause for adolescents. Yet, we have five different standards for each insurance plan for the most effective, evidence-based, lowest risk intervention.

Reimbursement in addition to dealing with the randomness of coverage has the greatest impact on the availability and access to psychiatrists.  For example, Magellan, which is the ‘behavioral health’ panel I must bill through for Blue Shield, reimburses me 20% less than Medicare. As such, I am one of two psychiatrists on their posted panel who is 1. alive and 2. Actually paneled with them. Many of these plans have ‘ghost panels’ which are now illegal in CA, but not sure who is enforcing this law if anyone. The result is psychiatry is the number 1 out of network specialty, more so than dermatology and plastics. It is a luxury now which it shouldn’t be.

I am providing this as background because I only started this practice with the aim of providing care that was accessible, not a concierge. But I am nearing a very difficult decision. When starting this practice my aim was to create a model where care was accessible—meaning it was not limited to those who could afford the out-of-pocket cost. Psychiatry is now the number one out of network specialty—why?  We are reimbursed at a rate that is lower than what is sustainable unless one hires multiple mid-level providers, limits appointments to 15 min med management.  That has never been my goal for practicing good medicine. As you all know, I am thorough and generous with my time, care is given in every detail—the whole patient is evaluated continuously—I am not an RX producing machine.

Changes

• As we are nearing our three-year mark, I am pleased to announce that we have grown in terms of services we provide, our space, and the number of staff.
• What has become increasingly difficult is managing the collection of payments from insurance plans.  We spend 20% of staff time on pre-authorizations, calls to insurance plans to collect on agreed-upon contractual codes in addition to pre-authorizations. It is becoming increasingly difficult to provide good care while fighting with insurance plans for agreed-upon contractual payments.
• We simply cannot spend the valuable staff time to do so as we are affected by the staffing shortages in the US just as other industries are.
• We have also had our staff grow in a positive direction which we are extremely proud of, but replacing them has been challenging. As some of you have noticed, Jackie, my MA of five years who helped me build this practice from the ground up is conspicuously missing—perhaps I have been in some denial announcing her move to Florida with her family. I am very happy for her but she is missed dearly and the vacuum she left is and will be difficult to fill.
• Thezia, perhaps one of the hardest working, most diligent employees one could ask for, has taken up by constant badgering about applying to medical school. She has done a tremendous job over the last year with us—really invaluable in so many ways. She will soon begin the process of applying to medical school, taking the final two classes in preparation for the MCAT.
• As such we will have all new staff and it will be a time of transition. Erika, an LVN who worked with me for 1.5 years at Altamed’s HIV clinic will be joining us full time in two weeks.  A new  MA-C, Roxana, started today. Both are hard-working, experienced, and with very positive attitudes (and Spanish speaking!).  Nonetheless, this will be a time of transition, which may impact the number of days we are able to provide care for at least a month or two until onboarding is complete.
• Things bring me to further limitations—we are also now spending more and more time trying to collect payment from not just insurance plans, but also patients for their deductibles and copays.
• This office does not have the administrative capacity to perform the functions of a collection agency if we are also going to be one of just two psychiatry clinics in the 20-mile radius that accepts insurance plans.
• Up to now, we have been very generous with outstanding balances, but this will be changing because it has to for this practice to be a healthy one.
• The time we spend trying to collect payments from insurance plans and now from patients has become onerous, making me consider joining the ranks of the 80% of psychiatrists (including the 5 in my building) who are not paneled.

Payment/Billing

I have not made a final decision, but I am seriously considering switching to a cash pay model all together with the exception of TMS and patients with Medicare (I am the only Medicare psychiatrist/neuropsychiatrist in the area).

Some plans, I have already stopped accepting as some of you know. Going forward, this list may grow if we continue to experience difficulty with particular plans. In general, my panel has been beyond capacity for all plans for over a year. If you have been added to my panel, it has been because an exception has been made.

In the interim, I encourage you to please read the contract you signed. It is your responsibility to verify your insurance coverage and exactly how much they are going to pay and to get a pre-auth number prior to your appointment. You are also responsible for knowing your co-pay. We do this for you as a courtesy, but it is ultimately your responsibility per the contract you signed.

• It is also your responsibility to pay for the entire cost of the appointment if you have a deductible—it is not our responsibility to continuously call you, email you, ask you, etc. for this payment.  
• You are responsible for knowing this beforehand.
• Out of courtesy, we will give your insurance 30 days to pay their contractual agreement. However, you are ultimately responsible for the cost of the appointment if they do not pay within 30 days of the bill submitted, which is in my contract with the plan and in your contract with me. You will be charged the cost of the appt on day 30, with 15 days to pay. You will be informed of your insurance plan’s denial and reason. It will be your responsibility to follow up with your insurance plan. Once it has been resolved and we have received payment from them, we will reimburse you for what they have paid.
• If you have not paid the balance in full and/or your insurance has not within the 15 day period after the first 30 days that late, your account will incur a $75 late fee (see your contract where this is explained).
• This late fee will continue to be added every 30 days.  At 90 days, your account will be reported to a credit agency and in accordance with California code, at day 150, it will be turned over to a collection agency.
• By the time your account is 60 days overdue, you will not be scheduled for any additional appointments.  I will no longer accept your insurance as a form of payment even when the account is paid in full.
• By day 90, you will receive a discharge warning with 15 days to reply. (Please review or ask for another copy of your contractual agreement with this clinic for additional information).
• We will not schedule any appointments without a valid credit card on file as well as a guarantor for your account should you default.
• Additionally, copays are due at the time of services rendered. The only exceptions made for paying them at a later date MUST be approved by me. I have a contractual agreement to collect a copay. If I collect some copays and not other copays, I can be accused of discrimination. As such, there will be a policy and formal requirements for financial hardship in terms of copay negotiation and only for TMS treatment—W-2 statements, a form will need to be filled out including an attestation.

For any questions regarding any aspects of this, please contact me directly at Torie@tmspasadena.com

Sincerely,

Torie Sepah, MD