Look to the OPPA and the APA to provide information to address the questions you encounter in the day-to-day practice of psychiatry: resources to guide you through the ethical, clinical and economic aspects of being a psychiatrist.
When an Insurance Company Denies Coverage of Services
Under Ohio law, patients (with their physician's assistance), may be able to appeal a decision by an insurance company when it limits or completely denies coverage of services. Appeals must first be made to the insurance company directly (known as the "internal review.") After a review, the company will send the patient a letter explaining why the appeal has been reversed or denied and outline the next steps.
If the insurance company denies, reduces or terminates a service or treatment because the plan determines the service or treatment is not medically necessary, the case could be eligible for an "external review" with an independent review organization. Physican experts knowledgeable on the specific medical conditions are employed by IRO's to review the case.
The external review is not an automatic process. The patient (with their physician's assistance, if so desired), must initiate an external review by contacting their insurance company.
Ohio's Internal & External Appeals Process
Regrettably, all too often, patients (with the assistance of their psychiatrists and/or the facility where services are rendered, such as an inpatient hospital setting) may not appeal all denied services. The OPPA has been working with the Ohio Department of Insurance to address ongoing and increasing problems associated with insurance companies denying services as "not medically necessary." OPPA members are encouraged to contact the OPPA to learn more about the appeals process, why it's important that all denied services be appealed and how you can get involved if you'd like to make a difference in addressing these types of concerns!
Understanding the Health Coverage and External Review Appeals Processes
A toolkit to help Ohioans understand the process by which they can appeal a health coverage claim denial made by their insurer.
- Annual External Review Outcome Summaries (Patient Protection Act Report)
Ohio Revised Code Section 3901.82(D), directs the Department of Insurance to compile and annually publish information regarding independent external review outcomes. Below are links to annual reports, summarizing data the Ohio Department of Insurance has collected regarding external reviews.
Improving Patient Care Through Communications Between Psychiatrists and Primary Care Physicians
In follow-up to a meeting between the OPPA and representatives from the Ohio Coalition of Primary Care Physicians, a "Patient Care Communication Form" was developed by the group as a way to improve communications and coordination of care for shared patients who see their psychiatrist as well as their primary care physician. OPPA members are strongly encouraged to utilize the form with every patient encounter!
To Participate, or NOT Participate? "Should I accept Medicare Assignment?" Those are the Questions!
For more than a decade, every year has begun with the possibility that Medicare fees will be cut significantly to satisfy a Medicare physician payment formula, known as the sustainable growth rate (SGR). While the AMA and APA continue ongoing lobbying efforts to have the SGR eliminated, it does not appear imminent.
With this in mind, psychiatrists may wish to consider their "participating" vs. "non-participating" status with Medicare.
Click here to find out how your decision impacts the amount reimbursed by Medicare.
Electronic Prescribing Alert
As you may already be aware, Medicare currently has an incentive program in place for physicians who do electronic prescribing (or e-Prescribing or e-Rx), which means transmitting a prescription electronically directly to a pharmacy.
Click here to learn more about the incentives (which began in 2011) and the penalties (which began in 2012) for NOT e-prescribing!