Why Reimbursement Will be Getting Harder: HCR, ACOs, Triple Aim, Telehealth and Your Wallet


Health Care Reform (HRC) is bringing unprecedented change, with much of it outside the awareness of the average behaviora professional. A new form of managed care began sweeping both federal (Centers for Medicare and Medicaid Services or “CMS”) and private healthcare reimbursement programs since January 1, 2013. Now well-entrenched, Accountable Care Organizations (ACOs) are moving into the next phase of health care reform: the planned, systematic movement away from “fee-for-service” reimbursement.

Common Confusion about “Fee-for-Service”

While many of our behavioral colleagues believe that “fee-for-service” refers to fees collected directly from clients/patients rather than 3rd parties, such a process process is more accurately referred to as “private pay.” With private pay, the client/patient funds their own care without the involvement of a third party such as an insurance company, agency funding or other outside party. Fee-for-service refers to getting paid for the service we deliver, which in behavioral care, is measured by time. For instance, our CPT codes reimburse us or minutes spent with a client/patient, such as the CPT code of 90837 for 53 minutes or CPT code of 90834 code for 38-43 minutes spent in a session. (For more specifics, see fee-for-service).  Across health care internationally, this model has been held responsible for less-than-optimal outcomes, inasmuch as the practitioner is rewarded for increased visits rather than for an improvement in evidence-based outcomes. 

Exchanging our time for a fee is therefore being “sunsetted” by Health Care Reform and systematically replaced by “value-based-care,” which will reimburse practitioners for outcomes. This shift has already begun in some of the more expensive areas of medicine, such as cardiology. Obviously, many things will need to change to see these effects in behavioral care, but they are well underway. The TeleMental Health Institute has been tracking these events for the last three years, and is now ready to begin sharing some of the facts we have uncovered. 

What does the shift away from fee-for-service mean for behavioral, substance use and mental health practitioners?

Accountable Care Organizations (ACOs)

You’ve probably heard of the new form of managed care that is rewarding professionals for delivering care in teams. Accountable Care Organizations (ACOs) have been experiments by many payer groups, including Medicare, Medicaid and several third-party carriers. Dr. West Olatungi, the former president of the American Counseling Association shared her views on this team-based approach for counselors in a recent TMHI webinar entitled, “Health Care Reform and Technology: A Conversation with Dr. West-Olatunji“. We’ll have a lot more to say about this shift over the next few months, but for now, we want to start by show you a recent attempt to pass new legislation that will encapsulate much of what has been predicted to directly impact our wallets and fuel the growth of healthcare technology. 

This past week brought a new bill that encapsulates the HRC’s Triple Aim effort as it combines ACOs and telehealth. Two legislators introduced “The ACO Improvement Act” (H.R. 5558), a bill that according to mHealth News, seeks to “improve the ACO model by providing additional incentives focused on health outcomes, increasing collaboration between patients and doctors and providing ACOs with additional tools.” It describes the team-based change in healthcare reimbursement described above which are experimental, irreversible (there is no going back to fee-for-service) and profound. Again, those repercussions will impact how we get paid.  

How Can You Learn More?

TMHI recently released a new program to help you understand and prepare for these reimbursement issues in the TMHI Advanced Certification Program’s “How to Get Paid” module. If features six of the interviews TMHI conducted with leading healthcare experts about health care reform and behavioral health. Please note: most of our guests for these interviews were not behavioral professionals. They included US Senators, a SAMHSA Senior Advisor, the CEO of the American Telemedicine Association, the CEO of the Center for Connected Health Policy and several others. If you want to know how telemental health will soon be one of the best alternatives to the type of change that is currently underway, register for this training today and get the inside track for your speciality area. 

If you are not yet committed to working online for at least a portion of your income and still have doubts, attend the TMHI’s October webinar to hear a quick outline of the financial changes that will soon be impacting our practices, and why telehealth is a viable solution for many of us. Take heart. This information is now at your fingertips and available 24/7 for you to absorb and implement at your own pace.

 Let me know if you have any questions by typing them below.

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