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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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The insurance companies will find any excuse to deny a claim, the system is very very broken!!
This article angers me on many levels. First, the 2013 CPT codes were released to all providers in October of 2012 so providers had plenty of time to educate themselves and their staff on the upcoming changes. Second, I bill for mental health providers as well as other specialties and I can tell you we have had a problem with only one carrier and that problem was corrected by the third week of January and all of our denied claims have been reprocessed. Third, our state Medicaid and multiple other entities offered free workshops and training conferences to help the providers understand the changes. They were FREE, everyone knew the changes were going to be extensive and expected an extremely large learning curve. If you did not prepare for the learning curve you have to take responsibility for that. Fourth, the fact this reporter used the threat of someone committing a horrific act to try to scare the public is shameful. There are multiple mental health outlets for the public to use and any responsible therapist would refer the patient to one of them if they were unable to help. Finallly, the statement that "most providers did not receive payments in January" is misleading. January and February are deductible months in our industry. ALL patients from ALL specialties will have their claims applied to their yearly deductible amounts during these months so payments are down for ALL providers from ALL specialties. So to say it is due to the coding changes is extremely misleading. There were over 700 CPT changes for 2013 only 30 pertained to mental health. The bottom line is either the provider mentioned in this article needs new billing personnel or did not take the necessary measures to prepare for these changes. He needs to look at his own back yard before pointing fingers anywhere else.
Really. I dont believe you. You state that the Doctors or clinics did not bother to go to your silly seminars, ETC. Who is supposed to pay for these Personell to go to a government run seminar? You people who continue to change things so as to confuse issues so that no one gets paid is just criminal. Over 700 code changes, all of you are absolutely crazy.
That's right, pass the buck and send them to horrible care if they can't afford it.
From a caregivers point of view, no sane caregiver is going to use county mental health care if they have a choice in it, ever. It's absolutely horrible.
The doctors want to argue over what they're getting paid, and the patients and their caregivers want better care. Prices go up and care gets worse. That's not anything new. It's been going on for over 40 years. The average cost for a new patient appointment was from $300-$500 for the first visit. That's without any "assessments". That hasn't changed, true. The cost of everything has gone up for everyone.
As a caretaker the problem is on all sides of the street in this picture. There are nine things that all people have to have and the caretaker is the one who has to make it happen not only for themselve but the person(s) they are responsible for as well. Guess who has to take less and less every time there's an increase to the doctors or the insurance ? Aside from the patients, the caretakers. Think of it like this, at least you get to go home at the end of the day.
Yes, it's real easy to pass the buck onto the county mental health system and make a referral. Maybe you should check out those referrals that you're making.
@wascigarman you can search the DMAS website yourself, i don't expect anyone to take my word, do the research. You can see the seminars that were scheduled. I didn't change anything the AMA did, a group that most of my clients do not belong to. My company simply kept our clients informed of the upcoming changes and gave them the educational opportunities as they presented themselves.
I truly do not understand your thinking though? How do you not cost justify sending personnel to an educational seminar that will in turn help your practice through new changes? I can tell you that our providers have seen little to no negative income changes due to these codes. It was because they were prepared and we stayed on top of things.
@Luci. No one is passing any buck. I was simply stating there are ALWAYS options. They may not be ideal but do not put out an article stating patients will HAVE to go without treatment when there are others who are capable and willing to help. Had nothing to do with caretakers, simply referring people etc.
Impeach Obama...
Grow up
PM. Still cant handle the Fact that a Black guy beat Romney and all of the Angry OLD White Geezers. LOL, hang in there, twenty fourteen is right around the corner, and a lot of your Old White Men will be gone. Republicans are Horrible People. IMPEACH ALL Republicans. LOL
In America, its all about the money, doesn't matter how sick or well people are its all about how are we going to pay, the article states that 20 percent of Americans are suffering from some sort of mental disease, yes its called greed and a totally screwed up health system. Illness is not measured by death, suffering, pain it is measured by dollars, I would strongly suggest that America gets its own house in order before it tries preaching to others.
Only in America! I swear, the one thing you can count on in this country time and time again is it's ability to take a simple solution to a problem and complicate it exponetially! Forgetting, in all the chaos, what is best for it's people and what needs to be done by creating a discombobulated system that serves no one. I can only imagine how other countries must be snickering at us right now - it's embarrassing, to say the least.
After reading this story i am truly disappointed. We are concerned with why we are seeing the rise in gun violence? Mental health issues are the primary reason we are seeing these incidents happen. Not to mention the amount of violence kids are exposed to in this digital age. It all starts at home, and ends in treatment for mental illness. If your uninsured forget about it! You will get passed along with no real treatment administered. But, now even if you are insured you have to worry about being cut off? Or benefits being decreased? We need to get are act together, it's almost too late!!!
The Affordable Care Act, aka Oboma Care at its finest! Remember, you can keep you health care providers, not have increases in taxes, nor have increased costs? All the current administration cares about is spending more, and more, and relieving us of our guns!
This has nothing to do with the Affordable Care Act this has to do with the Ins companies NOT getting their act together and the Ins companies screwing the providers and the insured again. If you have not worked in the Medical Provider environment you have no idea how much the Ins companies are screwing the American public. Ins companies are a legalized protection racket. So get off your partisan high horse and look at facts not propaganda from Faux, Beck or Rush.
You are nuts maybe 1% of the people in the USA are normal.The rest of the world has its own diff, like weman are not equal to man, they think we are lost. 50 years ago in Germany they had unisex bathrooms and the girls did not shave thier armpits, was that normal? Do the mongals wash their hair 2 times in their live time, is that normal? You call it mentally sick so you can get paid. I do not think I have to continue for it would take a life time to show all the diffs and by that time it would all change.
You are the classic definition of insane - everyone in the world is crazy, except you. Right? Riiiiiiiight!
Being able to denigrate righties on these blogs puts me in a good frame of mind!
Yep. More to come of this with King Obama
Ignore the facts and live in your own partisan world.
Capitalism giveth and Capitalism taketh away.
I hope this provider and others like him reads this post:
Just like other providers of health care services, mental health providers are making a living. I certainly don't begrudge them the right to do this, but I will say this: Blame it on whatever you want but unless a self-pay patient has plenty of money to spend,when a person's insurance benefit has been exhausted, they are kicked to the curb. And by that, I mean literally, put out. This is especially true with resident treatment programs. I saw a patient evicted on the 31st morning of a stay because she only had 30 days coverage. Her belongings were placed in a bag and she was wheeled to the front door after being told to call someone to pick her up. In her case, she had family who were making financial arrangments for her to stay. There were no other extenuating circumstances. It was all about the money. She is lucky though. This ridiculousness meant that she was placed in what turned out to be a better treatment facility after all. Most patients are not that lucky.
Unless the average person acts out in a dangerous fashion and is either taken to an ER by family or law enforcement, they remain without treatment and medications until either someone pays for it or a new benefit year begins. By the time either of these happen, patients who may have had a chance for a more permanent solution often degrade too far and end up much more ill that they should have.
In most states, the availablility of affordable mental health care is almost non-existent. And God help you if you are a person who worked most of their life and develops a psychological or psychiatric condition that interferes with going about daily like (like working). No one working in a local DFCS or SSI system want to give you the time of day. You aren't considered a minority (meaning Black or Hispanic or even better, a female Black or Hispanic), a wino or a meth head or a baby mama, it is next to impossible to get assistance.
What I hope everyone understands is that all of these things contribute to the numbers of homeless mental health patients. This contributes to families being worn down trying to care for someone they are ill-prepared to deal with.
Yes, providers should be able to make a living as should those who work for them. But like the medical and insurance industries, the entire system needs an overhaul and the National Health Plan is NOT the answer. In fact, it is going to make this worse. The taxes and penalties this plan includes are going to mean that more and more people are un or under insured. Yes we need affordable care that can be accessed by all on a level playing field in this country. I suppose we must keep working at it.
I hope that my state can get its proverbial act in order fairly soon.
Play lik a girl. You are blaming the wrong people. The Providers are the ones who are helping patients, it certainly is not the Insurance companies and our Government. Providers Provide a service, and have to get paid for that service from someone, there are no freebies, and never have been. When I worked, I could not have continued to work if my company said that they were no longer going to pay me. I suggest that you get your anger, and put it where it should be.
Obamacare is going to fix everything that is wrong with our medical system....and YOU are going to pay dearly for it.
Bottom line is the insurance companies wanna call the shots and don't care who suffers in the process....it's all about money and greed. And did I read this right " 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." or is this typical American media fear hype, because I would think that would be privilged between a dr and patient and if not were authorities notified? Personally I think it's typical american media fear hype BS to scare people
Got tinfoil?
Mymom. I have six huge rolls, Publix had a buy one get one free sale. I am prepared. LOL
Is there a medical code for that thing growing on the lower part of this poor doctor's face?
If I were the Doctors or the Clinics, I would just shut down. Most of these Doctors have enough Money to take it easy for quite a while. Shut down your offices and see how much action our government and insurers take to get there act together. If you do not work together on this, you are going to continually get screwed, and all of you nice Doctors who are using your Familys savings to operate your business, you are going to go broke. This is what Unions are all about, if a company starts treating there employees badly and not paying them, the Union shuts that company down thru STRIKE actions. If these Doctors are Smart, they will shutter there offices and clinics, until they start getting paid.
don't you think that is rather simplistic thinking. what about the ethical, moral, and may i mention LEGAL issue of withholding treatment.
rocco. If your office or clinic is shut down, there is nothing ILLEGAL, all the Doctors have to do is lock there doors and say they are out of business, Nothing Illegal about that.
Let the chaos begin, as more and more Obama voters start to realize how screwed they are.
The only reason people are getting screwed is because haters like you refuse to accept the will of the people and move on..Thanks for that....
This is what happens when you have a world obsessed with money instead of the betterment of mankind
So... what?
These people are quacks, and their patients need to "cowboy up".
That's what everyone else does.
you, sir, are a moron.
idiot's! it's not about the billing and it's not about the money; sorry to say it's not even about the patients. it's about an entirely broken, underfunded, poorly managed in every imagineable way, system of care for the mentally ill. the bush administration did a very extensive study by the "leading experts"on the mental health problem in the us. essentially this two inch thick doxcument reported just what i told you, oh did i mention this report came out in 20001. nothing happened. but, we sure need to jump on gun control! has anyone figured out that its the nut behind the trigger that's causing all the problems.
I am a mother of an adopted son who just turned 15. He was mentily, physicly,and sexuly abused by his Bio-Mother. If thats not enough he also suffers from autisum, r.a.d (reactive attachment disorder) an mildly retarted just to name a few of his dissorders. He has been in theiropy for most of his live an up to this point it has been less then addequate becouse we are on the medical card. I will admit my family an i feels he needs to be in a hospital for intense theiropy becouse he is so full of pain an hatetred an becouse of his dissorder he dose not know how to let the pain go. on meany occasions he has told me that he hears voices that tell him to seek revenge an kill the poeple who have hurt him. He has attacted my husband breaking his ribs an myself on more then one occasion. we have discussed these matters with his mentil health caregiver to try and get him the help but they say unless we get the police invalved we can not have him commited. An we feel that we should not have to wait for him to do something realy bad like act out his fantisy of killing someone to get the help he needs. I love my son with all my hart but i am also scared of him an what he my do becouse he can not get the help he needs. With all the shootings in the news lately we as a nation ask ourselves how this can happen. well being a person that lives every day with a mentily ill person can tell you. Its becouse the mentil health community is failing an not at fault of their own but becouse of the goverment. becouse the mentil health community has their hands tied by the goverment my son can not get the help he so despertly needs. An i feel that someday becouse he doesnt get the help he needs NOW i will be on the news in the futrue trying to explain why my son went off the deep end and killed one or more poeple. It breaks my hart to think this of my son but i feel it will come to pass becouse he dosent get the help he needs.
As a caregiver and not a doctor you need to let the mental health courts issue a warrant and the sherriff's department pick him up and have him committed. It is the hardest thing you will ever have to do but sometimes it's necessary. It is your responsibility not only to him, but to everyone else. It is not a failure on your part. Yes, you should be able to take him to the hospital and get the help and long term care that he needs. You have taken the hardest job possible by adopting a mentally ill child. Try finding an advocate with NAMI, the National Alliance of the Mentally Ill to help you. He may actually need assited living nursing care specializing in mental health and they can help you assess if that is the case. You need help in developing a plan of action and what to do and when.
To Luci and Isis I have dealt with this situation and unfortunately the way this system is set up, when the police are involved with taking your child in for help, you are adding a criminal element into your childs future. The police, on average,are not trained to deal with the mentally ill, and many times exacerbate and escalate a situation that leads to violence to the patient. Mentally ill people are warehoused in JAILS where they receive no treatment and are ridiculed and threatened by the criminal population. This results in isolation of the ill, which is the exact opposite of what is needed. Turning our children in to become convicts is NOT the answer!
If you need to resort to the police for help, and your child does get to a mental health facility, the average stay here in NYS is EIGHT DAYS. Not even long enough to evaluate how new medications are going to effect your loved one. Most SSRI's take 4-6 weeks to take effect, by then you are long gone, and no one knows how the patient is faring.
Before you call the police, call your Representative and TAPE that call! Call NAMI and tape that call, call the police if you have to, and tape that call, but use the non-emergency number and calmly explain the situation and ask for an officer skilled in mental health issues. Generally a female officer is much more sensitive, not always, to mental health situations. The less testosterone and reactive, aggressive attitudes from those who are already in power the safer all our children will be.
Thank you Melissa and Luci for your respones to what i wrote. I am working on trying to get him placed but like Melissa stated i dont think bringing the police into our situation is the answer. just becouse he is mentilly ill dosent mean i need to give my son a criminal record just to get him help. I feel we need to get him the help befor it comes to that. I want to help him not add to his troubles. He has been through alot in his short life an i realy dont want to couse more harm to his condission. I just wish it could be easier to get the help we need for him without fighting tooth an nail to get it befor its to late.
So to recap, the RWNJ philosphy is as follows;
We dont want to be supporting freeloaders, even if they are mentally ill.. Let them have all the guns and ammo they can have, without bans, without restrictions; just so long as I nor the government dont pay one tax payer dime to any entitleistic suggestions such as expanding liberal mental health programs.
Put armed guards in every school, until its time for a conservative to make a budget, then delete that line item to save a few bucks.
So they all knew it was coming, and waited until it hit the wall to do anything? Scamerica at its finest.
Peace
Looks like the Obama adminstration is getting its hands dirty in the gun violence debate. Loose cannons everywhere now.
Oh what a load of sh-it this is.
The only reason people are not getting care is because of f---king money, and why is that?
I see billions being spent on FN wars, drones, bank bailouts, guys in Wall Street who do crack then f--k everyone with there gambling addictions or should I say predictions, congress getting high on insider trading, insurance companies sticking it too the customers and employers, and the sh-it just keeps on coming.
If only we could get rid of all these mother f---king spend thrifty bas-tards we might just find some cash for helping sick people.
The president and every other one before this guy all got drunk at the helm as did just about every other pr-ick who helped them get elected
Now they complain we have too many wing nuts walking about pumped up with billions of dollars worth of that mind numbing Prozac induced zombie medication which makes enough money too pay for just about any or all medical needs.
but noooooooooooooooooooooooooooo!
They would rather just say "We don't have enough to pay for these poor sick bastar-ds"
So what do they do next?
Take it from your taxes, and blame every single American for not contributing enough out of what little they still have in there FN pockets after the biggest heist in American history came along in 2007-009.
These mother f---kers make me sick, and I don't mean mentally! but I'm getting there real soon with all the sh-it they have been getting away with over the last 20 years or so.
When is someone going too say f---k!!!!, I had enough of this...........time too kick some presidential, Wall Street, lobby sucking congress a$$$$$$$$$$!......
The simple answer?
When hell freezes over, or we all end up blown away by some million dollar drone that was invented too protect us all from ourselves.
WTF!!! ? is going on with this nation?
We have tons of money, or should I say the Fed seems too have no problem printing lots of that sh-it when it comes too handing it out to the very same f---ks who helped screw us all in the pie hole, but they would never think too use that mother f---king printing press to give a little in helping some sick half baked wanna be killer who they claim is the main reason for wanting to take away everyone's right too protect themselves.
Now do you see a problem with this BS?
I do.........
So many of us around the world see what you are saying. Your country is a miserable mess. A big part of the problem is the mindset of the average American...always pointing the finger at the President (Democrat or Republican). Your democracy is not working anymore, I am sad to say.
Your right..........sad too say, but true.
The way of the people has destroyed the people and the nation has been run by those who could care less about the people.
War is all we make anymore and soon it will be right at our front door.
Sad nation in flames we have become our own terrorists and enemy of the state by the state.
I like your vocabulary, you would fit right in with our congress, that is about how smart they are. LOL