private insurance and New CPT

1
private insurance and New CPTs

• Private Insurance and NEW CPT (Current Procedural
  Terminology) Codes
• Terminology
• Review contracting with insurance
• Review old and new CPTs
• Summarize differences between old and new CPTs 
•  

2
Insurance Terminology

• CPT Current Procedural Terminology
• In Network provider that accepts an agreement
  with an insurance company
• Out of Network provider that sees patients, but
  does not have a contract with an insurance
  company
• ICD 9 International Statistical Clarification
  of Disease version 9
• QHCP Qualified Healthcare Provider
• Rendering Provider the healthcare provider that
  actually saw the patient.
• NPI National Provider Identifier
• DOI Department of Insurance
• AMA American Medical Association
• Best Fit CPT a cpt used as a best fit when
  there is no AMA code.
• Claim a billing form submitted to insurance for
  services provided

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Insurance Terminology

• Technician a person who is not a BCBA or BCaBA
  but practices under supervision. Also called a
  para or therapist.
• CAT III CPT a temporary code set used to gain
  data on utilization of services. Used to
  determine if formal cpt codes are needed for a
  given medical service.
• UNR usual and reasonable rate. (according to an
  insurance company)
• Max Allowable Fee Same as UNR. The maximum the
  insurance company will pay for a given service.
• Unit cpts are based on time units. Some are
  15 minutes per unit, some are 1 hour per unit,
  some are not time specific but product specific
  (like a progress note). The AMA determines the
  cpts unit, not the insurance company or
  provider.

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Contracting in vs. out of network

• Services can be provided as an out of network
  provider, but there are limitations.
• If there are other in network providers in the
  area (within 50 miles) you will be subject to
  their negotiated rates despite what you charge.
• In network usually allows easier claim submission
  and access to the companies website for claim
  info.
• In network is subject to lower out of pocket cost
  for the patient.

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Contracting in vs. out of network

• Going in network involves the Contracting
  department of the insurance company.
• You will need to fill out a complete application
  as an individual provider (just you), or a group
  provider (your company, but you will bill for
  other providers)
• Rates are offered in what is called a fee
  schedule. Even if the insurance company says
  the fee schedule is not negotiable, it usually
  is.
• The exception is if there are multiple providers
  in the area, then the rates are pretty much
  established.

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Contracting in vs. out of network

• How do you know if there are providers in the
  area? Go to the companies Provider Directory.
  
• Or have the member call and ask for a Board
  Certified Behavior Analyst.
• When there are no providers in a 50 mile radius,
  you can request a single case agreement. This is
  only for the 1 patient, but you can request to be
  treated as in network if the company doesnt
  have another provider.
• This helps lead to negotiations.

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Understanding IN Network vs. Out of Network

• Deductibles Much higher for out of network
  providers.
• Deductible amounts are specified in the
  individuals policy.
• In Network vs. Out of network reimbursement.
• If there are no in network providers, the
  health care company must treat out of network
  providers as in network.

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In Network vs. Out of Network

• Sample Comparison 100 for a service
• In network pays at 100 plus 40 co-pay
• Out of network pays 80, benefits do not start
  until a 2000 out of pocket deductible is met.
• In network client pays 40 dollars per day. No
  deductible. Insurance company pays 60
• Out of network patient is responsible for the
  first 2000, then 20 per hour of service.
  Insurance pays 80 per hour.

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Best Fit cpts

• Companies not using the NEW AMA CPTs will
  continue to use best fit codes.
• Common cpts to Humana and United
• H0031 Assessment development of treatment plan.
  1 hr unit
• H0032 Supervision of paraprofessional. 15 min
  unit
• H2012 Day Treatment, direct services 1 hr unit
• H2019 Therapeutic behavioral services 15 min
  unit

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Best fit CPTs

• Humana Only
• 90889 prepare patient psych report
• United Only
• H0032 for graphing, report updates, revision to
  plan.

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New AMA category III cpts

• In July of 2014, the AMA put out new cpts for
  ABA services.
• The new codes are temporary codes that are
  being used to establish the need for further
  development.
• Insurance companies, and providers are NOT
  MANDATED to use these codes.
• Unless you are in network, and agree to use these
  codes.

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New AMA category III cpts

• New cpts are much more specific, and require
  separate codes after the first unit of service.
• The new codes do allow billing for services that
  werent always billable.
• The new codes do not allow billing for some
  services that used to be billable (supervision).
• The new codes do not require billing by the
  technician, but rather the QHCP.

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New AMA category III cpts

• When you negotiate a rate with new cpts, the
  technician is considered a practice expense.
• That means, you bill the same amount if a
  technician sees the patient as a BCBA, in regards
  to treatment cpts.
• Some cpts are only billable by the BCBA (0359T
  behavior assessment).

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New AMA category III cpts

• 0359T Behavior Identification Assessment (flat
  rate 90 minutes). For initial assessment/FAI/inte
  rview/initial observation.
• 0360T Observational behavior follow-up. First
  additional 30 minutes needed for direct
  observation and data collection. (ABC data,
  Baseline Measurements, direct assessment
  methods).
• 0361T Each additional 30 minutes of direct
  observation.
• Notice that what used to be billed as H0031 for
  most companies is now billed under 3 different
  CPT codes.
• 0362T Exposure behavioral follow-up assessment.
  This is for a Functional Analysis or modified
  functional analysis. Used for severe challenging
  behaviors. Administered by BCBA and at least one
  or more technicians.

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New AMA category III cpts

• 0363T Each additional 30 minutes of follow up
  exposure assessment.
• 0364T Adaptive behavior treatment by protocol.
  First 30 minutes of treatment. Requires protocol
  or behavior plan.
• 0365T Each additional 30 minutes of treatment
  by protocol.
• 0366T Group adaptive behavior treatment by
  protocol. First 30 minutes
• 0367T - Additional 30 minutes of group adaptive
  behavior treatment by protocol.
• 0368T Adaptive behavior treatment by protocol
  with modification. First 30 minutes. Used to
  modify the protocol. Data indicate that the
  protocol is not resulting in the expected
  behavior change.

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New AMA category III cpts

• 0369T Additional 30 minutes of adaptive
  treatment with protocol modification.
• 0370T Family adaptive behavior treatment
  guidance. Can be used for consulting/training
  family members or caregivers. Patient does not
  need to be present. 60 Minutes.
• 0371T Multiple-Family group adaptive behavior
  treatment guidance. 90 Minutes. Supposed to be
  used when you can train a group of
  parents/caregivers on behavior procedures.
• 0372T Social Skills Group. 90 Minutes. Up to
  8 patients max.
• 0373T Exposure adaptive behavior treatment with
  protocol modification. 60 minutes. Requiring 2
  or more technicians.
• 0374T Additional 30 minutes of exposure
  adaptive behavior treatment with protocol
  modification.

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New AMA category III cpts

• The new cpts are much more specific to the type
  of service you are going to render.
• Most treatment cpts require an initial 30
  minutes cpt, then 30 minutes follow-up. This
  could mean that you have to use the initial cpt
  0364T, then 0365T for each additional 30 minutes
  for that day.
• Some companies have said they will use the
  initial cpt 0364T for the first unit of service,
  then 0365T for each additional 30 units per
  authorization period (usually 6 months).
• 0364T, 0365T seem to overlap with 0374T, 0375T.
• The main difference was the word Exposure.
• Exposure seems to apply to more systematically
  contrived treatments, and is described as being
  more appropriate when treating more SEVERE
  problem behaviors (aggression or SIB).

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Summary

• New CPTs will require a lot more planning when
  trying to do a prior authorization.
• Hard to know when you will need Adaptive
  Treatment Protocol Modification, ahead of time,
  so a new authorization request may be needed if
  treatment data are not meeting goals.
• New CPTs may require billing 2 cpts per day of
  treatment, or the initial and follow-up cpt per
  authorization period (will vary by company).
• Not all insurance companies will use the new
  cpts. Sometimes the same company may use the
  new cpts in one state but not in another state.
  
• Do not use the new cpts unless you are
  contracted to do so.
• Writing of reports and behavior plan is not a
  billable service.

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Summary

• New CPTs include recommendations to bill all
  services under the QHCP or BCBA. This is good
  because it eliminates billing technicians, and
  can minimize claim denials as duplicate services
  when 2 therapists work with the client on the
  same day.
• New CPTs allow insurance company have a more
  clear picture of exactly what service you are
  will provide.
• It is not yet clear how an insurance company will
  determine medical necessity for treatments such
  as family training (0307T).
• It is not yet clear how an insurance company will
  determine medical necessity for modification of
  treatment protocol.
• It is not yet clear how fee schedules should be
  adjusted to include for training of the
  technician and report writing. There are NO
  cpts anymore for staff training or writing up
  the modification to the protocol.

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Summary

• Consider carefully how the use of the NEW cpts
  could impact your business or practice. Factor
  in costs.
• We will see in a few years if these CATIII
  temporary CPTs become permanent cpts. That
  review will be done by the American Medical
  Association after they have data on CPTIII use.
• Read and review the resources on ABAIs website
  regarding the new cpts.