Increased Coverage of Interprofessional Consultations

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Increased Coverage of Interprofessional
Consultations
On 5th Jan 2023, the U.S. Department of Health
and Human Services (HHS), through the Centers for
Medicare Medicaid Services (CMS), issued
guidance that creates an easier path to specialty
care for Medicaid and Childrens Health Insurance
Program (CHIP) beneficiaries. This increased
coverage of interprofessional consultations
allows direct payment to consulting
practitioners, expanding access to specialty care
and reduces the administrative burden to treating
practitioners. For the first time ever, state
Medicaid and CHIP programs will be able to pay
specialists directly when a beneficiarys primary
healthcare provider asks for advice. For example,
if a pediatrician consults with a specialty
behavioral health provider about a specific
patients needs, both providers may be reimbursed
for their care, even if the patient is not
present. This move links routine care with
specialty care, allowing more people to benefit
from practitioners with specialized
knowledge. CMSs previous policy prohibited
coverage and payment of interprofessional
consultation as a distinct service because the
presence of the patient was required under that
earlier policy guidance for specialty
consultation services to be directly covered.
Under the previous policy, the treating
practitioner was paid an increased payment rate
for a covered Medicaid service, which could have
included costs for the consultation activities.
The treating practitioner would then have to pay
the consulting practitioner out of that payment
rate through a separate arrangement between the
two providers.
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Increased Coverage of Interprofessional
Consultations
This approach was administratively complex and
created barriers to specialty input on
beneficiary care. This new policy will expand
and expedite access to specialty care, allowing
beneficiaries to benefit from experts with
knowledge of their particular health condition.
The new policy eliminates the need for consulting
providers to coordinate payment via separate
agreements with the treating practitioner, giving
Medicaid and CHIP the flexibility to develop
payment methods to reimburse consulting
practitioners directly for their services.
Importantly, these consultations can occur when
the beneficiary is not physically present,
ensuring personal and geographic barriers do not
stand in the way of connections to
care. Defining Interprofessional
Consultation Interprofessional consultation is
defined as a situation in which the patients
treating physician or other qualified health care
practitioner (i.e., treating practitioner)
requests the opinion and/or treatment advice of a
physician or other qualified health care
practitioner with specific specialty expertise
(i.e., consulting practitioner) to assist the
treating practitioner with the patients care
without patient face-to-face contact with the
consulting practitioner. Interprofessional
consultations are especially important for
improving access to providers who specialize in
child and adolescent behavioral health.
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Increased Coverage of Interprofessional
Consultations
Coverage for Interprofessional Consultation in
Medicaid and CHIP To be coverable under Medicaid
and CHIP, interprofessional consultation must be
for the direct benefit of the beneficiary. This
means the services must be directly relevant to
the individual patients diagnosis and treatment,
and the consulting practitioner must have
specialized expertise in the particular health
concerns of the patient. Interprofessional
consultation is intended to expand access to
specialty care and foster interdisciplinary input
on patient care. It is not intended to be a
replacement for direct specialty care when such
care is clinically indicated. Interprofessional
consultation services may be covered under a
variety of Medicaid state plan benefits, such as
physician services, services of other licensed
practitioners, and rehabilitative services.
Regardless of the benefit, to be covered under
Medicaid or CHIP, both the treating practitioner
and the consulting practitioner must be enrolled
in Medicaid or CHIP. For consultations that cross
state lines, consulting practitioners must be
enrolled Medicaid or CHIP providers in the state
in which the beneficiary resides, though they
need only be licensed/credentialed in the state
in which they are practicing. Both the treating
and consulting practitioners will be required to
follow all state and federal privacy laws
regarding the exchange of patient information.
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Increased Coverage of Interprofessional
Consultations
Medical Billers and Coders (MBC) is a leading
medical billing company providing complete
billing and coding services. We shared billing
updates on increased coverage of
interprofessional consultations for provider
education purposes. You can email us
at info_at_medicalbillersandcoders.com or call us
at 888-357-3226 for billing and coding
requirements.