New Medicaid Dose Optimization Initiative to Take Effect November 14, 2013
The Medicaid Fee-for-Service program recently established a new Dose Optimization program, which will seek to reduce prescription costs by limiting the amount of pills a patient needs to take each day, while retaining daily dosing amounts. This initiative is expected to result in significant cost-savings for the Medicaid program, since, in many cases, pharmacies charge per pill dispensed.
Obama Administration Issues Final Rule Implementing Mental Health Parity and Addiction Equity Act
On Friday, November 8, 2013, the Obama Administration issued a Final Rule implementing the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA). In general, NYSPA and the APA are pleased with the Final Rule, which includes clarification on many important issues, including insurer transparency, nonquantitative treatment limitations and reimbursement rates, among others.
To read the APA Talking Points on the Final Rule, please click here. To read the APA Talking Points on the Parity Law in general, please click here.
DOH Establishes Transition Period for I-Stop Compliance
As you know, the new I-Stop duty to consult goes into effect on August 27, 2013. The Department of Health recently posted the below message on its website, which indicates that all practitioners unable to establish an HCS account and access the PMP despite good faith efforts may continue to write prescriptions for Schedule II, III and IV medications. DOH expects this period of transition to last through October 2013.
The New York State Office of Mental Health (OMH) recently announced its Regional Centers of Excellence Plan a plan that calls for major changes in State-operated mental health services, representing a shift from inpatient services to community-based services.
Significant HIPAA Changes to Take Effect September 23, 2013
Earlier this year, HHS issued a Final Rule that makes significant changes to the existing HIPAA privacy, security and breach notification rules. The compliance date for the Final Rule is September 23, 2013.
Court Finds Plausible Parity Violations by United but Requires Claims To Be Brought Against Plan Sponsors
On October 31, 2013, United States District Judge Colleen McMahon dismissed a class action mental health parity lawsuit brought by four patients, a psychologist, a psychiatrist, and NYSPA (on behalf of its members and their patients) against UnitedHealth Group
The New York Times recently published an article entitled "Lacking Rules, Insurers Balk at Paying for Intensive Psychiatric Care," which addresses the failure of health insurance carriers to cover the cost of care for individuals with serious mental illness.
NYSPA/APA Successful in Reversing Improper Denials of Claims Submitted To UBH/Optum
NYSPA was recently contacted by two members who had been receiving improper denials from United Behavioral Health/Optum for claims for the new combination psychotherapy CPT codes (e.g., 99212+90836), Optum was refusing to provide reimbursement for the psychotherapy add-on code because the provider had failed to document start and stop times for the psychotherapy portion of the session alone (as opposed to the E/M portion). This practice, clearly in violation of CPT, was being applied to both in-network and out-of-network benefits.
In response to our recent website article on the new PQRS 2015 payment reduction, NYSPA has received several inquiries from members regarding the use of Measure #9 (Major Depressive Disorder (MDD): Antidepressant Medication During Acute Phase for Patients with MDD).