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Glitch in medical code threatens mental health care, therapists warn

Jennifer Shephard / Jennifer Shephard for NBC News

Psychologist Marc Milhander, 54, says he's weeks away of having to close his Niles, Mich., counseling center after delays and denials in insurance payments caused by an overhaul of treatment codes.

Published at 4:45 a.m. ET: Marc Milhander conducted more than 100 psychotherapy sessions in the first few weeks of this year, treating patients ranging from the mildly anxious to the severely depressed and the 24-year-old with antisocial personality disorder who really wants to get his hands on a gun.

But Milhander, 54, a psychologist who co-owns a busy Niles, Mich., counseling center, is getting pretty anxious himself.

He’s among a growing number of U.S. mental health professionals who say their insurance claims have been denied -- and their payments have been withheld -- because of problems resulting from nationwide changes in psychotherapy treatment codes that took effect Jan. 1.

“I’ve been paid for five hours of work for the month of January,” said Milhander, who supports a staff of four and oversees 300 patients a month. “I just wrote a big, fat check out of my personal bank account to keep us afloat.”

Worse, Milhander and others say systemwide delays and outright denials of payment could last for months, jeopardizing not just the nation’s 500,000 providers, but also access to care for millions of mentally ill Americans. Federal estimates suggest that nearly 20 percent of the adult U.S. population has some form of mental illness.

“So far, it’s chaos,” said Randy Phelps, deputy executive director for the American Psychological Association, who says hits to the coding section of the APA's website have topped 300,000 in the past month. “It’s hard to evaluate how widespread this is.”

The problem comes amid growing demands for better interventions with the mentally ill in the wake of shooting massacres in Aurora, Colo., and Newtown, Conn.

“Compliance with treatment is a sketchy thing to begin with,” said Sam Muszynski, director of  the office of health care systems and financing for the American Psychiatric Association. He fears that financial fallout may force some providers to disrupt care, leaving mentally unstable patients on their own temporarily -- or longer.

“All it takes is one missed appointment,” he added.

The trouble stems from the first overhaul since 1998 of the codes used to describe -- and bill for -- mental health treatment. They’re among some 8,000 to 9,000 CPT, or current procedural terminology, codes used for all types of medical procedures. 

The codes, produced by the American Medical Association, are updated each year, usually with no problem, experts say. But this year, changes to a mere 30 codes that affect mental health services have thrown a huge glitch into the system.

“There are some systems that aren’t even ready to begin accepting claims,” said Nina Marshall, director of public policy for the National Council for Behavioral Health.

She has been flooded with calls and e-mails, not only from providers confused about how much to charge and when they’ll get paid, but also from patients worried about care.

“I have heard from consumers saying that their providers can’t provide the services,” she said. “They’re reaching out to me with real concerns.”

The psychiatric codes were updated after vigorous lobbying by mental health care providers, who argued they weren’t being paid enough to treat today’s medically complex or seriously ill patients.

“What has come out of managed care in mental health is they go in for three days, they’re on meds, they’re barely stabilized, and being treated by outpatient providers,” Phelps said. “Nobody had reevaluated these codes for 30 years, but the world had changed tremendously.”

Payers unprepared

But the implementation has been difficult, at the very least.

Payers, including the federal Medicare and Medicaid programs, admit they weren’t prepared for the switch.

Some providers have used the new codes incorrectly -- or not at all, a violation of federal law. Some government contractors logged extra "edits" into the codes, invalidating scores of submissions, Medicare officials told NBC News. Three weeks into the new system, federal officials had to send directives reminding everyone of the changes, said Brian Cook, a spokesman for the Centers for Medicare and Medicaid services.

“As soon as we became aware of the problem that some of our Medicare contractors were having, we immediately took steps to fix it and instructed the contractors to re-process the incorrectly denied claims," Cook told NBC News. "We also informed Medicaid State Agencies and private insurers to prevent any widespread problems.”

The nation’s largest private insurers have had problems, too.

“The amount of changes and the work involved was much bigger than … the folks involved anticipated,” said Helen Stojic, a spokeswoman for Blue Cross Blue Shield of Michigan, where Marc Milhander practices.

Stojic couldn’t say how many Michigan claims had been denied or how many providers had been affected, but she acknowledged that many had not received payments in January -- and that there was no firm date when they would.

“We’re going to do everything possible to get some dollars to them,” she said. “We certainly apologize for the inconvenience.”

For Milhander, the issue is far more than an inconvenience. He says worried about keeping the doors open with so little money coming in. 

“Right now, we’re working for free,” he said.

Steven Perlow, president of the Georgia Psychological Association and a psychologist in private practice, says he hasn’t received January payments from private insurers, either.

He, too, has heard from dozens of frustrated colleagues worried not just about cash flow but also about code changes that shave more off of insurance payments. One change, for instance, trims a typical therapy session to 45 minutes and cuts reimbursement by $1 each time.

“It’s just $1 less, but nonetheless, we’re being asked to take less,” said Perlow, who sees about 45 patients a week.

The biggest worry, though, is that the coding chaos will affect care for vulnerable patients fortunate enough to have some form of insurance coverage.

'A really large job'

About 46.5 million adults in the U.S. -- or nearly 20 percent of the population -- suffer from some form of mental illness, according to government statistics. About 11.5 million suffer from serious conditions.

It’s not clear how many actually have access to care, but many do not, and anything that jeopardizes existing support is a problem, experts say.

“We are ethically bound not to leave patients hanging,” Perlow said. “I will personally see people for a sliding scale … there have been situations where I’ve seen people for free.”

Milhander said he, too, would continue to treat patients -- including the most severely ill who require medication management -- as long as possible.

“My staff are understandably panicked, fearful that they won’t have the financial resources to get through this,” Milhander said. “I’m letting them know I will carry them through this period financially, for as long as I’m able.”

How long the denials and delays may last is anyone’s guess. Medicare officials say they’ve begun reprocessing claims that were denied in the first weeks of the year. But for some Medicaid programs, the problem is so complex that they may not be able to get up to speed to process claims until June, experts tell NBC News.

Private insurers are aware of -- and working on -- the problem, said Susan Pisano, a spokeswoman for America’s Health Insurance Plans, an industry association.

“Implementing these codes is a really large job,” she said, noting that some plans are offering alternate payment processes until the problem is fixed.

Still, some providers may stop participating in insurance plans that delay too long, or cut fees, and others might be forced to close shop entirely, unable to go for weeks or months without income.

'How scary is this?'

That’s a frightening thought to the family of Milhander’s 24-year-old patient, who suffers from paranoid delusions and only recently has been stabilized under the psychologist’s care.

“Marc is the only person that he is able to talk to. This is his only release,” says a family member, who asked not to be identified, even broadly, for safety reasons.

The young man suffered a head injury as a teenager. He has threatened to burn the house with people in it, threatened to get a gun, threatened to "come back and haunt" family members after his own death. 

“We hear about these scary things that happen. How scary is this, now that the insurance is having these issues?” said the family member. “How many people are going to be left untreated out there?”

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