Thursday, May 10, 2012

Is NY State taking steps toward a paraprofessional delivery model for their Early Intervention Program???

New York State has an electronic information management system for the Early Intervention Program that involves a mechanism for billing and reporting services to the municipalities and state.  This system is called the New York Early Intervention System and is generally referred to as NYEIS. 

I received email today regarding use of procedure codes in the NYEIS system and I want other practitioners to be aware of some issues.

The email describes the difference between Level I and Level II HCPCS codes.  In quick summary, Level I codes are also referred to as CPT codes and are standard and typically accepted codes that represent the professional activities of licensed health care professionals.  Some of them are rather specific and include things like "OCCUPATIONAL THERAPY EVALUATION" or "PHYSICAL THERAPY EVALUATION" or "THERAPEUTIC EXERCISE."  Some insurance companies don't approve of some of these codes, particularly if they think that there is not enough research or evidence to support the interventions (like SENSORY INTEGRATION THERAPY). Still, most of those CPT codes are reimbursed by private insurance.

Level II HCPCS codes often refer to services that are not provided by physicians or health care professionals like DME suppliers (durable medical equipment, prosthetics, orthotics, and supplies - all often referred to as DMEPOS) , educational services, and other services or items that are typically not 'covered' by standard insurance. 

The email from the DOH states:

The Bureau of Early Intervention has reviewed these (Level II) codes with the Office of Health Insurance Programs (OHIP) and Medicaid. OHIP and Medicaid agree that there is no concern or restriction with special educators or other non-healthcare professionals from utilizing HCPCS codes for Early Intervention service claiming...The following HCPCS codes have recently been added to NYEIS and may be appropriate for special instruction or other non-healthcare professional services:
G0176 - Activity therapy (such as play, etc.) for care and treatment of patient's disabling mental health problems, per session (45 minutes or more)
G0177 - Training and education services related to care and treatment of patient's disabling mental health providers per session (45 minutes or more)
G0451 - Development testing, with interpretation and report, per standardized instrument form
H0004 - Behavioral health counseling and therapy, per 15 minutes
H2000 - Comprehensive multidisciplinary evaluation
H2014 - Skills training and development, per 15 minutes
H2027 - Psychoeducational service, per 15 minutes
H2037 - Developmental delay prevention activities, dependent child of client, per 15 minutes
S9445 - Patient education, not otherwise classified, non-physician provider, individual, per session
V2799 - Vision service, miscellaneous
T1016 - Case Management, each 15 minutes
T1017 - Targeted Case Management, each 15 minutes

Now that might seem innocuous, and providers may simply think that there are now more options for coding, but let's review some realities before people jump to using these new codes.

If you use a Level II code (and you are not a specified DMEPOS provider) on a standard HCFA-1500 billing form to just about any commercial insurance company that I know of you will not get paid for services.  Additionally, you will most certainly NOT be paid for maintenance, developmental, or educational Level II codes.

Last year I documented that New York State had an 85% denial rate for reimbursement from commercial insurers, and even a 22% denial rate for simple intra-agency billing to the Medicaid program - which is pathetic.  I am struggling to understand why the state would encourage use of codes that are KNOWN to be denied by commercial insurers when they already have a gigantic billing/collection problem.  Now they can make whatever rules they want to make their own Medicaid program pay those codes but that will do nothing for the commercial insurance aspect of billing.  Using Level II codes will contribute to more commercial denials.

Promoting use of Level II HCPCS codes can only mean they are incredibly misinformed and clueless OR they are throwing in the towel with trying to get reimbursement and they intend on replacing skilled services with services provided by non-licensed people with 'generic' developmental training.

What's that again?

Yes, other states around the country have replaced occupational, physical, and speech therapy services with paraprofessional services provided by non-licensed human service professionals who usually hold generic child development degrees/training.  Those paraprofessionals certainly are not entitled to bill standard CPT codes to insurance companies.  They certainly ARE entitled to use Level II HCPCS codes - and now it seems that NY State is paving the way for it to happen.  It is much less expensive to have paraprofessionals provide services than licensed professionals.  The States don't bother trying to collect the commerical side of things, write rules for Medicaid to eat as much cost as possible, and just go the paraprofessional route.  However, the larger question is whether or not it really meets the needs of children and families.

Bottom line is that we (as a society) probably can't afford all of these programs, and the only way to even try to afford them is to either tax people into oblivion or develop cost saving models like the use of paraprofessionals.  Is that coming to NY State Early Intervention?  Talk to your colleagues around the country in Florida, New Jersey, Colorado, and many other places and see how the use of paraprofessionals has impacted care delivery in their Early Intervention Programs.

Either way, use of Level II HCPCS codes will contribute to continued inability to collect reimbursements and will collapse the system, or it is reflecting a mood-shift where we are setting up a system that will make greater use of paraprofessionals.

Be ready.

Sunday, May 06, 2012

Speech to occupational therapy students and parents: Ways You Will Be Paid.

I was invited to speak at a PTE induction ceremony.  Here is the text of my speech.  Please excuse the vernacular and form; it was written for oral delivery:


Hi everyone and thank you for inviting me to speak to this group.  It is an honor to be invited and I want to congratulate all of the students for their excellent efforts and performance, I want to congratulate the parents and family members for all that they did to lay the foundation that made this excellence possible, and I want to congratulate the faculty for all of their contributions that also helped with the achievements we are here  to celebrate.

Pi Theta Epsilon was not in national existence when I went to occupational therapy school, and I am so pleased to see how it has grown and flourished in the last 25 years.  Students frequently ask me "Is is worthwhile to participate in things like PTE?"  I always answer with a heartfelt YES!!!.  Over the course of my own occupational therapy career I have been a part time academic but I have always been a full time clinician and I own a private occupational therapy practice.  When I see membership in PTE on an employment application that tells me a lot about a candidate.  It tells me that they can achieve.  It also tells me that they are interested in promoting research and scholarly activities.  In the real world that means they are going to be better clinicians.

Today I wanted to take this opportunity to talk to you about your upcoming transition from students to practitioners, and I hope that this talk can also can be an opportunity for your families to reflect on your accomplishments and the steps you will be taking.  I think that like most things in life there is some good news and there is some bad news.

Let's start with talking about your student loans.  Ugh!  That is the bad news part.  I know that is not a happy topic for many students and in many families.  My son is done with college, one daughter is now enrolling in a Physician Assistant program after completing an undergraduate degree in Biology, another daughter is a Sophomore Occupational Therapy student at Keuka (!!!) and my youngest will be going to college in another year - so I have a little familiarity with the topic of paying for college.

Nationally, student loans have topped the $1 trillion mark.  That's a lot of debt.  I am willing to bet that some of you own some of that debt!  Although Keuka fares relatively well in supporting students with aid I know that student loans and debt are still a big concern, especially with the prospect of the interest rates potentially doubling for new loans starting this summer.  That is a big deal and I don't think we should ignore that problem, but I don't want you to spend too much time focusing on it. 

Let me give you a different way of thinking about all this.  That is where the good news part is.  According to the Bureau of Labor Statistics, employment of occupational therapists is expected to increase 33 percent from 2010 to 2020, much faster than the average for all occupations.  In a recently published jobs ranking occupational therapy was listed as number 7 out of 200 jobs.  So the good news is that there is a lot of work out there waiting for all of you.  And that is why I want you to think so carefully about where you are going to take that first job and what factors you are going to allow into your thinking when you are trying to make decisions about where you are going to work.
Here is where your PTE participation can really help you.  Let me explain.

Because you are PTE members I already know that you are all big thinkers.  That means you are going to remember everything I said about job demand and opportunities.  It also means that you are going to remember everything about what you learned regarding people and their occupational needs.  Then you are also going to remember how powerful your profession is and that you are ready to meet those occupational needs.

You see, focusing on the BAD NEWS of debt and choosing employment primarily for the purposes of ameliorating that debt situation in the short term might not be the most important thing to focus on.  Want to know why?  I am going to tell you something that you might not have ever really thought about before, so please listen closely:

The people who need you the most might not be able to pay you the most. 

And now you also know that with such a good employment outlook for the long term you might not need to make your initial employment decisions based so heavily on your financial status.

That's heresy, I know - everyone wants to find the best job that offers the best pay.  BUT - the best job might not actually OFFER the best pay - and that is what I want you to remember:  The people who need you the most might not be able to pay you the most. 

Pay you the most money, that is.

The best news of all is that I am relatively certain that over time your loans will in fact be paid off.  It is likely that you will have many productive opportunities as an occupational therapy professional - and this is precisely why you won't only have to think about financial factors when you are making decisions about work.

So did you all enter into this profession with the express purpose of making the most money?  You likely want to make some, and you likely want to pay your student loans, but what has your schooling and PTE participation taught you about big thinking?  What do you know about the wise words of the people who developed the philosophy and theory of our profession?  And what do you know about the occupational needs of the people who come to you for help?

Mary Reilly, one of our profession's greatest theorists and clinicians, told us in her Eleanor Clark Slagle lecture that needs are an indispensable part of human nature and imperatively demand satisfaction.  What societal needs will you serve?  Should we be so concerned about the salary of our first job?  Or should we spend some of our big thinking time concerning ourselves with how we are going to help others and meet their occupational needs?   And while we are at it, should we consider what we are going to pay back in service to everyone that has helped us get here??? 

Or in other terms perhaps I mean pay forward. 

The way that you choose to pay back all of your "debts" is what will make your family or your parents sit proudly in their chairs at graduation.  Imagine what they are going to say about your first job.  They all have a part in this, you know.  In every way that your Mom and Dad and Family cared for you and helped you grow into the fine people that you are, in every way that this Faculty pushed you and encouraged you and contributed to your learning - all these acts and all these efforts converge at the point of action when you go to see your first patient and say, "Hi, I'm going to be your occupational therapist.  I am really excited to work with you - let's start by you telling me what your goals are."

At that single point in time everything that you know about human needs will come into a directed call for YOUR action, and you will be standing on the shoulders of all these other people who made it possible for you.  All of their efforts to support you will be suddenly transformed into your ability to help others.  It is an amazing thing.

So pay your debts.  Once a month you will get a bill in the mail from some loan servicing center, and instead of dreading it and instead of making it the focus of all your efforts you will instead be paying attention to this new calling in your life, because once you learn to focus your attention on the needs of the people who you are called to serve - a lot of other things will fall by the wayside.

And then you will be paid.  You will be paid in ways that you never before imagined.  You will be paid in the voice of the young child who comes to your clinic and says, "I told my teacher that you are my BEST FRIEND!"  You will be paid in the thanks from the father who will tell you "I had no idea how to be a good parent for my baby and I am so thankful for everything you have helped me learn."  You will be paid by the hope in the eyes of a student athlete who thinks that he might be able to recover from his hand fracture and return to his team by the end of the season.  You will be paid by the sight of the Army private who stands in full military dress uniform that he put on himself, even though he did it with two prosthetic arms that you taught him how to  use.  You will be paid by seeing the young adult who has an autism spectrum disorder be able to move out of her parent's home and into a supported living apartment.  You will be paid by the firm handshake and deep appreciation by someone who might remind you of your grandfather, because you remembered to understand his needs and to be kind to him and to respect his dignity while he was in a nursing home and re-learning how to be independent after a hip replacement.  In so many ways you will be repaid.

And those monthly payments to the loan servicing center will seem very small and inconsequential.  Mostly because with all these ways that you are going to be paid, you will be wealthy beyond your wildest dreams.