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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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Just what we need: throwing away money on a make-work program for expensive psychologists under the pretense of preventing violence.
Why in God's name does the A.M.A. update the coding procedures annually? It probably generates more money for the physicians so they implement an unnecessary change that's going to cause the collapse of the Mental Health care system in the United States.
I know most psychologists and psychiatrists are capable of interpreting the new coding changes and they have skilled code specialists in their office too. What gives?
What this is should be clear, it's a typical bureaucratic failure at the highest levels. Abandon the code changes and revert back to last year's codes. Insurers are simply screwing the pooch in order to save a buck on the backs of the mentally ill.
Coding changes are not done by the doctors and providers. They come from the insurance companies. This costs us money to implement.
thank you tard obama and i would like to say to all you moron libs told you so. welcome to the free health care. oh wait as long as i have a job to pay for your helath care plan. will only get worse.
Sue, this has nothing to do with the president no matter who it is. This has to do with coding changes that are done every year. The insurance companies do this every year. Its nothing new. Pay attention for heaven's sake.
okay obama keep thinking it.
wow. lol Tell me how the coding changes have to do with Obama again? Please prove me wrong. Although this is what I do for a living. But please. Show me.
Typical right wing argument.. your stupid, your retarded, your a jerk. If you have a valid point to argue, then please do so, if not, then you are Re-pub-tarded.
This is just another example (of far too many) of how the United States has fallen and become a 2nd world nation. So many other 1st world countries are doing so much better on health care (all levels of it), among many other things. The US is resting on its laurels and its propaganda. The only big thing you have left is an army and that's dwindling too. People around the world are watching you and the free-fall you're in.
By the way, Obama is not to blame. Your fall started the moment Clinton left office. Your primary problem: you make absolutely everything about money...and that has gotten you to where you are right now...broke and desperate.
You are so right about our country going down hill since President Bill Clinton left office. However, the coding problem has been an ongoing problem for years. This phsyician should have prepared for the changes knowing that each time there is a change there is usually a hold up in payments.
Aside from that the coding changes have to occur to keep the code up to speed with advances in the medical field and to be more explicit as to what treatment is being provided, in the hopes that the clearer the information is the more likely the insurance carriers will pay. But health insurance companies do not want to pay, the longer they hold onto the money the more interest the gain.
It's time that we put these insurance carriers out of business and have a universal healthcare. However, the conservatives see this a socialism!!!!
@hair metal rocker: If the U.S. is so crappy, why is it usually the first nation to respond when another nation has a natural disaster? How many aircraft carriers does your country have that can be used for peaceful relief efforts -- such as providing electricity, food and medical care? What do you consider a "1st world" country? England? France? Oh, please. Two times we had to help lift the yoke of oppression from their necks. Maybe you should clean off your own doorstep before you start in on ours.
When everyone or nearly everyone agrees that the gun violence is partially due to the mental health system this is a bad time to screw up that part of the medical system. The doctor who said he has a mentally ill patient who wants to get his hands on a gun can report him to the authorities. I was more concerned about the HIPPA laws regarding third party notification or release of information. Common sense will tell you if they aren't paid they will go under. Several years ago there was a lot of complaints about the doctors insurance premiums and a lot left the specialities to go practice general medicine. Obamacare is going to throw millions of new patients into the system that not only is not going to add doctors but they are cutting the time per visit for evaluation and they are withholding payment. Leave it to Obama.
Chalk one up for the insurance companies. Wonder how Obamacare will impact us when it goes full tilt. We'll have to purchase insurance but they won't have to pay. The liberals will sleep well at night knowing we're all covered.
If 'codes' were costing insurance companies money, you can bet they would be fixed post haste.
As we slide down into the rut known as Obamacare, we will see lots of self-serving glitches. That's what happens when you bet the farm on the ability to control huge greedy corporations to the publics benefit, corporations that we have never yet been able to regulate with any predictability.
When we get the magic middlemen out of the picture, restore competitiveness, and increase people's access to ongoing preventative healthcare, we might have something to be proud of.
This mess we have now only promises to get a lot worse.
I am one of the 11.5% who are seriously mentally ill. I have been in treatment since I was 8 years old and had a very bad episode last year. I don't know if it is a result of these new codes or just that I have crappy insurance, but in the past couple of months I haven't been able to find ANYONE who will help me. I am having extremely expensive treatments at a major hospital, and I'm paying $1500 out of pocket per 10-minute visit with a psychiatrist, which I can't afford and I don't know what is going to happen to me when my savings is depleted. The truth is that the healthcare industry doesn't care about the mentally ill. And to those of you saying this will lead to more violence, have you ever met a mentally ill person? I have never hurt another human being in my life, and know many other people with mental illness, and none of them have become violent towards others. Stop blaming the mentally ill for what "bad" people do.
ECF, I would check your state legislation. For example, in KY, an insurance company must treat mentally ill treatment as an actual medical illness and can not treat it differently. For example, my daughter has bipolar and ADHD and social anxiety disorder and asbergers. I'm told everytime I call the office to schedule her appointment my insurance will not pay for it. I tell them regardless to what my benefits state, the state law supercedes it (stupid billing department). Then they go look it up and call the insurance and THEN the insurance says oh yeah and pays for it. I would check your local laws regarding your treatment.
No one is saying that mentally ill people are bad people. We all know that they are not. But we also know that if those people are not treated that they can do bad and in some cases evil things. You must admit that. I will and my daughter is one. I know that although she knows things are bad and wrong and knows the difference, she has no self control or impulse control. And once it is done she has regret and is upset with herself. that is why she is on medication. Also with that in mind, notice than many of those that do a crime and then kill themselves, they do have regret. Those that do not kill themselves have no regret.
jen, Thanks for the tip. The issue is actually that my insurance is so crappy not a single doctor or therapist in my area will take it. The hospital I go to weekly for treatment takes the insurance in most depts, but not the psychiatric dept. When I went to a covered hospital, it was the most disgusting, horrible place I had ever been and I have sworn never to go back. My employer was trying to not let me change my insurance, but I have a lawyer helping me now.
You, as a parent to someone with bipolar (which is what I have as well) know that the mentally ill are not "bad" people. But I hear so many people, including friends and relatives who are otherwise intelligent, make diagnoses on people who kill or otherwise do evil, often based on a photograph because he has "crazy eyes." They'll assume he has bipolar or schizophrenia, when these armchair psychiatrists have never taken a psychology class or known anyone with any kind of schizophrenia. People do blame the mentally ill indiscriminately, and because of the assumption of violence in bipolar patients, I lost custody of my children when my husband left me and I had to fight like hell to even get to see them on Saturdays. There is a lot of prejudice out there against us.
Oh hun, I know and I'm so sorry you had to go through that. And you are right, bipolar disorder is one that people they think they know all about. When they don't. And people are just evil. Its sad. Try again to check for the laws in your area like I mentioned. You might get some leway there anyway. Good luck hun.
Can you say, 'insurance industry cluster f$&k?
This code change happened before and claims got denied as non-covered services. Blue Cross Blue Shield sold twice during the three to four months of non-payment. I finally got a check by wailing about how was I supposed to pay quarterly taxes. It still wasn't anywhere near full amount for some time after that. If any of the private insurance companies are up for sale this time, buyer beware. They should have to pay us interest for this.
Ugh, many people keep talking about "psychopaths who are going to shoot everything up". While there is the possibility of someone with mental illness with violent tendencies not getting treatment and actually becoming violent, most people with mental illness aren't dangerous or are dangerous only to themselves. There are many more people with moderate or severe mental illness that will never be dangerous to other people will not get the help they need and will deteriorate so that they're suffering greatly or unable to care for themselves.
From personal experience I know that insurance companies will do everything possible to avoid paying out to practitioners. This occurs in all areas of health care, but seems to happen even more where it comes to mental health care.
And just where are you getting your "facts" that they only hurt themselves? Tell that to the people's families that got killed in the movie theater in CO., or to the people in AZ, that that nut Loughner shot and killed and maimed....
And while you're at it, take a trip to Conn. and tell that to the families of the kids killed there. I'm sure you'll find a lot of believers in those "facts" you're spewing...
NeedsARichUncleTOO...where am I getting my information? From my own experience as being mentally ill for almost 40 years, during which time I have never even hit another person, let alone shot them. And I have been in treatment with hundreds of other people with mental illness, none of whom ever became violent towards others. The man in Colorado, and the one in Connecticut were BAD PEOPLE. They were not just mentally ill, they were evil. BIG DIFFERENCE.
Looks like the Feds are gonna get more loonies killing more people so they can take ALL of our guns away....don't you just love it when an agenda becomes apparent to anyone with a brain, and STILL manages to work out? doh!
Needsa Rich Uncle...You are an ass and I am no longer responding to you.
Oh for the good old days when there were no medical insurance companies. I do remember when the doctor's office sent the bill, and wages were sufficient enough so that you actually paid the bill and that was the end of it.
Medical insurance on the one hand is a form of legalized robbery, and on the other an adjunct to the information age that wants more more more statistics about everyone.
I predict that in 10 years healthcare will go the way of the U.S. Post Office - employing people who would rather be doing something else, and losing money for the government, and supplying less good care, all as a result of reducing healthcare workers/physicians to the performance demands of burger flippers.
Saying "your money or youf life" used to be a hanging offense. You're right, medical professionals were paid by the customers, sometimes through simply Medical Indemnity policies.
Now we have MBAs making medical decisions. At best they're practicing medicine without a license.
"I predict that in 10 years healthcare will go the way of the U.S. Post Office - employing people who would rather be doing something else, and losing money for the government, and supplying less good care, all as a result of reducing healthcare workers/physicians to the performance demands of burger flippers."
That's actually the way it is in the VA Healthcare System. I've been told THREE times now by 3 different "doctors" at the VA that there "isn't anything we can do for you.", yet, when I went to a "private" doctor, he set up a treatment plan, to treat me, but I am unable to afford his prices...and the VA won't cover it, because I have a VA clinic locally that they said I could go to....
An exceedingly warm afterlife? And beign charge of your health care, they can expedite the trip.
Is this a great country or what?
needsarichuncletoo,
You VA must prove to you that they can not do anything for you and if there is somewhere else that you know that they can do something for you, then they must pay. True story. I worked in billing and coding for years. If the doctor that you found is a good doctor and their billing office are worth a darn, then they will help you appeal. Also, what do you mean you can not afford their prices. Do you have Medicare and a supplement? Can they work out a finance plan for you?
"I predict that in 10 years healthcare will go the way of the U.S. Post Office - employing people who would rather be doing something else, and losing money for the government, and supplying less good care, all as a result of reducing healthcare workers/physicians to the performance demands of burger flippers."
Sorry to have to tell you this, but as an individual that has worked in medical billing for over 20yrs, they have been working on this for as long as I know. Just look at some of the job postings for medical billers. The ones that could advise, and are expected to appeal and collect on these claims. Though there are classes for coding as well as billing (which I would not waste my money on, & found out through unemp they are a scam. They hire you for 6 months, and then lay you off. Plus healthcare managers have found certified billers less knowledgeable then those with hands on training.) Requires even at highly reputable facilities will be listed as a highschool diploma. Experience too expensive!!
20 children murdered by a psychotic, & the for profit medical industry leaps into action; denying coverage for mental illness. How much proof do you need before you realize providing health care on a for profit basis is insane in itself.
And no, socialism doesn't even need to be considered. Just give the current health care companies 90 days to refile as non-profits. The private health care system is preserved, the professionals still get paid, & competition is for charitable donations. A competition that can only be won by curing the sick, healing the injured, & improving everyone's quality of life.
BTW, for those of you blaming Obama, Obamacare doesn't kick in until next year. All you're doing is exposing your bias.
And still nobody's be able to explain to me how a board chairman's yacht improves our health.
BTW, Obama Care has its fingers in the pie as of 01/01/2013 operating costs were effected for insurance providers, thus initiating premium increases from 4 to 12 percent depending on the individual plan structure for dependent children coverages of each insurance company. So is it you who is showing your bias or propensity to be a sheep?
"OBAMACARE" did not affect the coding process. this happens every year. it happened under Bush. Wow, do we really like blaming people much?
"operating costs were effected for insurance providers, thus initiating premium increases from 4 to 12 percent depending on the individual plan structure for dependent children coverages of each insurance company."
Obviously you are unaware of the expenses incurred in the HealthCare industry regarding HIPPA Compliances as well as implementation of electronic medical records. Expenses including security system keeping people out & requiring each employee with an electronic badge to enter their work place. Much more expensive than the insurance carriers expenses!!
Fire the gov! KICK ALL OF CONGRESS, IRS, USPS, RICK PERRY, ETC OUT OF AMERICA!! They broke the America Family!!!
To be fair, it's the folks who own our "representative" (yeah, right) who've done all the damage.
Could the government intervening in practices and procedures in mental health care be a prelude to another effort to disarm citizens? According to these numbers about one fourth of the population has some form of mental illness, with the proper coding we may all become legally mentally ill and not able to purchase guns. Just a question.
Nah. It'll be when you're called out to join the militia. Someone has to deal with the economic disruption caused by OWS, Tea Party, & civil rights protestors, & above all, striking workers. Of course there'll be violence, & you'll be asked to do the right, patriotic, best-for-your-country thing & surrender your weapons.
What breaks my heart is how many of you will do it.
As the lib and economic guru paul krugman said yesterday, we have no choice. We must implement Death Panels. Sorry Sarah, you're were right
This is about GREED the mental health care providers wanted more money, the insurance companies have not adjusted their premiums in advance of theses changes because they already increased them by 10 percent to subsidize Obama Care. They are now suspending delaying payments in a effort to recoup these additional expenditures initiated by greedy mental health care providers. Have faith pepole goverment controlled health care will help us they will provide every thing we need all you have to do is sit back and wait.
1 out of 5 people are mentally ill. Guns are everywhere.....beam me up. If any aspect of health care isn't more important then I don't know what is. This guy should have an accountant handling his billing/coding....
Having worked as a Medical Biller for over 20yrs this happens everytime there is a coding change. It doesn't matter if the change involves CPT, ICD9(diagnosis coding), or HCPC codes. The insurance carriers especially the the government payers are always the last to update their systems. Yet physicians, and hospitals are expected to have their systems all implemented before the effective date. All of these changes are made with advanced notice and there really isn't any true excuse as to why the insurance carriers can not have their systems updated prior to the effectiveness of the change.
However, I have learned with insurance companies it's all about holding onto the money not paying it out. Furthermore, though I feel for the patients, the medical field looks down on billers and in the past year has reduced the salaries of their billers to what they were paid 10 years ago. So the fact that the doctors are complaining that they are being asked to accept $1. less does not phase me given that when I apply for a job they are asking me to accept up to $9.00 an hour less.
This war between phsycians, insurance carriers and patients has been going on far too long and the only ones that wind up paying the price is the patients. Something has to change, patient care should be the top priority.
Not all patients being treated for mental health issues are "psychopaths". There are millions of people being treated for mental health issues that are non-threatening to the public, sadly, there are some that are left untreated or misdiagnosed and horrible, tragic results ensue whether taking their own life, drug/alcohol addiction, or taking the lives of others. The solution isn't to ridicule people with mental health "issues" (I hate that terminology) but to make quality (there are a lot of unqualified personnel out there) mental health more acceptable and available and take the stigma off of these diseases. If you look at the events leading up to these tragedies, someone knew their were signs that the person was not behaving normally, but for whatever reason chose not to report it or get them the help they needed. As for insurance companies, they need to start treating mental health issues as other "normal" health issues so that people can get the coverage they need to be able to afford the start of their recovery process. Also, family physicians need to stop prescribing anti depressants willy nilly and send patients to specialists where they will be monitored. With gun control, making mental health records accessable to the public, disregarding HEPA rules, is just taking a huge step backward as patients will either stop treating their mental health issues, start getting their medications from other questionable sources, or not go through insurance at all,taking huge steps backwards; soon we'll be treating mental health patients by by tying then to the beds, doing lobotemys and performing experiments on them (not that I'm naive to think it doesn't still happen today in some facilities!)
How dare anyone expect to make a profit off of others sickness. (Rolls eyes)
funny how you all shift the blame on the insurance industry no matter what the problem is and yet a good percentage of them are not for profit carriers like most of the blues. And the most profitable carries made 5% while the drug manufacturers average 18% . Don't believe me, have guts enough to get out your card and see if is says you are a member or an insured, if a member you are in a not for profit "membership" that simply shares, the cost of care. Of course we didn't fix that except to add a tax, YOU will get it soon LOL
The Blues are by far the most screwed up insurance company on the planet, they could not make a profit even if they had a total monopoly on the health care field.
I'm not convinced that there is any real treatment for mental issues. How often do we read about some nutjob who had treatment going on a killing spree?
I've been working in the insurance industry for 41 years, so I know. I can say with absolute assurance, insurance companies have no business providing health care.
With the exception of cosmetic & elective surgeons of course, nobody undertakes the headaches of patient billing, malpractice insurance, maintaining professional standards, etc. just to get rich. Leave health care to health care professionals, not CEOs with MBAs.
Can anybody explain how a board chairman's private jet enhances our health?
I have appearently missed something somewhere here! I know of NO ONE who travels to their health Insurance Agency for any medical treatment! Are people so different where you are from?
My dealings with my Insurance Agent is strictly in respect to what treatment they will cover and at what price! That type of decision is very definately in the pervue of CEO's!