Practicum Journal – Reimbursement Rates

Reimbursement rates and medical coding can be almost as complicated as treating some mental illnesses. As a PMHNP, you will be faced with varying rates that may be different than other health care providers you may work with.

In this Practicum Journal Assignment, you will analyze reimbursement rates for mental health treatments you will likely use in your practice and compare those rates to other provider rates.

Learning Objectives
Students will:
Analyze reimbursement rates for mental health treatments
To prepare for this Practicum Journal:

Research reimbursement rates for various treatment modalities.
Compare NP rates to other provider rates.
For this Practicum Journal:

Complete the Reimbursement Rate Template in your Learning Resources using the five types of services you are likely to use in your practice.

ANSWER

NURS 6670

The Current Procedural Terminology (CPT) refers to a medical coding system that reports surgical, diagnostic, and medical services and procedures to professionals such as health insurance firms, physicians, psychiatrists, and accreditation institutions. The American Medical Association (AMA) created the system to accurately identify and report medical professionals’ services in a way that other entities can universally understand. The CPT system is an essential part of the billing process of medical professionals and combined with ICD-10 codes allows insurance to cover a procedure and reimburse a health service provider. The rates for reimbursement, however, differ from one expertise to another in the medical field. For instance, the PMHNP reimbursement rates vary from those of physicians. In contrast to physicians, PMHNP’s practices are on a much smaller scale with regards to finance, specialized medical equipment, staffing requirements. This results in a disparity that overburdens the PMNHP’s practices who are consequently unable to fully collect a considerable reimbursement amount from the insurance companies (Kohler, 2015).

To that effect, this paper analyzes the rates of reimbursement for various psychiatric treatments to utilize in my practice. Presently, the rates of reimbursement for five different modes of treatment are available. The five methods are individual psychotherapy 30 minutes for outpatient, psychiatric diagnostic evaluation, group therapy (not multi-family 45-60 minutes), and 45 minutes with patient or family member, and psychotherapy 60 minutes with patient and/or family member. These five types of services will complete the table below from the AMA (2017).

Table: Reimbursement Rate Template

Type of Service eg. -New office visit -Established office visit -Inpatient hospital -individual psychotherapy -group psychotherapy (see examples below)	CPT code	Private insurer reimbursement rate for PMHNP	Private insurer reimbursement rate for physicians	Medicare the reimbursement rate for PMHNP	Medicare the reimbursement rate for physician
Psychiatric Diagnostic Evaluation	90791	$123.4	$151.75	$116.79	$124.96
Individual Psychotherapy 30minutes outpatient	90832	$60	$74.25	$35.67	$41.72
Psychotherapy, 60 minutes with patient and/or family member	90837	$81.96	$89.90	$111.64	$115.70
Psychotherapy, 45 minutes with patient and/family member	90834	$63.84	$65.56	$73.57	$92.75
Group therapy, not multi-family 45-60 minutes	90853	$23.86	$29.53	$25.26	$25.75

From the above reimbursement rates table, it is evident that the physician’s reimbursement rates are higher than those of the PMHNPs. In both government and private insurance companies, the rates of reimbursement for the physicians is higher than those of the nurse practitioners. However, some private insurers pay more than the government for some of the services that they provide. From the table, Medicare pays more for psychotherapy concerning the patient and family members both for the 45 and 60 minutes sessions. The individual psychotherapy and the psychiatric diagnostic evaluation reimbursements are more for private insurers than those of Medicare. Some of the private insurers that pay more for certain services include Aetna, United Health Care, and Anthem Blue Cross (Wyome, 2020). The above table values are based on the aforementioned private insurers but their rates vary from state to state. The variance of reimbursement rates depends on several factors such as location, specialization, license, and client demand at the signing of the agreement (Wyome, 2020).

Mental health service providers whose level of education is higher will receive higher rates of reimbursement as opposed to those with lower rates (Bishop et al., 2014). Medical physicians require a longer time to complete their educational and clinical training than PMHNPs. As such, the physician’s higher level of expertise and education allows them to undertake complex procedures more advanced than those of the PMHNP. For the PMHNP to get higher reimbursement rates than their professional counterparts is to move to a high-end region such as New York or Manhattan. The reimbursement rate system for the two professions has been a topic for debate for a long time and there has been no consensus on whether or not the type of health insurance is a factor.

However, a recent change to the CPT coding system provides an opportunity to examine the important issue of why insurers reimburse physicians more than they do PMHNPs (Mark et al., 2018). One of the reason why this is the case is that the PMHNPs have a lower participation rate than the physicians. A recent study showed that the number of psychiatrists who participate in insurance are very low. Moreover, to address the disparity, policy makers need to make sure that the PMHNPs and other medical professionals receive equitable incentives to improve participation in insurance programs and comparing the rates of reimbursement for similar diagnoses and services.

References

Bishop, T. F., Press, M. J., Keyhani, S., & Pincus, H. A. (2014). Acceptance of Insurance by Psychiatrists and the Implications for Access to Mental Health Care. JAMA Psychiatry, 71(2), 176. DOI:10.1001/jamapsychiatry.2013.2862

Kohler, C. (2015). Physician Practice Billing From A to Z. Brentwood, TN: HCPro, a division of BLR.

Mark, T. L., Olesiuk, W., Ali, M. M., Sherman, L. J., Mutter, R., & Teich, J. L. (2018). Differential reimbursement of psychiatric services by psychiatrists and other medical providers. Psychiatric Services, 69(3), 281-285.

Wyome, K. (2020, January 17). Insurance Reimbursement Rates for Psychiatrists [Updated 2020]. https://therathink.com/insurance-reimbursement-rates-for-psychiatrists/