Introduction: Defining Interprofessional Consultation
In a January 5, 2023 letter to state health officials, the Centers for Medicare & Medicaid Services (“CMS”) clarified a Medicaid and Children’s Health Insurance Program (“CHIP”) policy regarding coverage and payment of interprofessional consultations (the “Directive”). An interprofessional consultation occurs when the patient’s treating physician seeks the opinion and/or advice of a qualified physician without the patient having face-to-face contact with the specialist. The new CMS directive clarifies that it is permissible for Medicaid and CHIP to provide reimbursement for an interprofessional consultation when the consultation is for the direct benefit of the patient without the patient being present.1
Previous Policy: Expert Care Advisory Support
Previous CMS policy did not allow coverage and payment for interprofessional consultation absent the patient’s in-person visit.2 Instead, the treating physician was paid an increased rate of payment to include the consultation where there was a separate agreement between the treating physician and the consulted professional. CMS’ previous policy regarding interprofessional consultation was seen as complicated and creating unnecessary barriers to care.3 The Guidance supersedes the previous policy that prohibited interprofessional consultation coverage and payment as a separate service, as direct coverage for a specialist required face-to-face interaction with the patient.4
Mechanism: Coverage and Payment Process for Interprofessional Consultation
For interprofessional consultations to be covered by Medicaid and CHIP, the consultation itself must be for the direct benefit of the patient. The benefit to the patient must be relevant to the patient’s care, and advice from a specialist practitioner must come from within the specialist’s field of expertise.5 In order for interprofessional counseling to be covered by Medicaid and CHIP, both the treating and counseling professionals must be registered in their state as a Medicaid or CHIP provider.6 Since counseling may cross state lines, the counseling practitioner must be enrolled in Medicaid or CHIP in the state where the patient resides, but the counseling practitioner must be licensed only in the state in which they practice.7
Regarding the payment structure for interprofessional consultations, each state has the ability to create its own reimbursement methodology for such services. Under the Guidance, CMS is establishing interprofessional consultation as its own separate service where payment can be made directly to consultant providers, which can be adopted independently by individual states.8
Importance of interprofessional consultation coverage: Improving patient care
The role of interprofessional consultation is to expand access to specialized care and promote interdisciplinary contribution to patient care.9 Team-based patient care has been shown to improve patient outcomes and safety by reducing medical errors.10 Specialists and the attending physician have unique perspectives and valuable patient insights that lend themselves to a more comprehensive, holistic view of patient care. A physician’s busy lifestyle may not allow for face-to-face collaboration with other physicians in patient-centered care. Technology and consultation compensation are bridging the gap for increased efficiency, synergy and assurance. CMS has given states expanded flexibility to use telehealth to deliver services and expand the availability of interprofessional consultation.11
Interprofessional collaboration combats medical errors, creating an improved patient experience that delivers better outcomes. This results in an overall reduction in healthcare costs.12 With interprofessional consultation coverage encouraged and payment structures streamlined by CMS guidance, it is expected that interprofessional collaboration will flourish because there is increased efficiency and reduced costs for health care entities. CMS has enabled states to have an interdisciplinary collaborative approach.13
The role of states in interprofessional consultation payment structures
States have the choice of whether to pay for interprofessional consultations.14 If they choose to do so, they must submit a State Plan Amendment (“SPA”) to add a payment methodology for eligible interprofessional counseling services.15 CMS strongly recommends that states review and consider the billing code and payment rates established by CMS when deciding on state payment rates for similar services. Alternatively, states could also consider incorporating behavioral health codes that allow consultation among physicians.16 States are encouraged to change or eliminate the same-day billing limitation because it defeats the purpose of collective consultation and prevents the integration of patient-centered care.17
Conclusion: How to make guidance work for healthcare entities
CMS aspires to develop and promote access to specialty care by reducing the existing administrative burden on treating physicians.18 This change in direction gives states and health care entities the opportunity to create a win-win scenario that benefits both patients and providers. Based on the Guidance, practitioners will be able to increase the use of interprofessional consultations that have the potential to improve patient outcomes while reducing overall healthcare costs.
Footnotes
1 Centers for Medicare & Medicaid Services, Coverage and Payment Interprofessional Consultation in Medicaid and the Children’s Health Insurance Program (CHIP) (Jan. 5, 2023) – *SHO 23-001 – Interprofessional Consultation (medicaid.gov)
2 Centers for Medicare & Medicaid Services, Opportunities for Designing Innovative Service Delivery Systems for Adults with Severe Mental Illness or Children with Severe Emotional Disturbance (November 13, 2018) Opportunities for Designing Innovative Service Delivery Systems for Adults with Severe Mental Illness or Children with Severe Emotional Disturbance Disorder (medicaid.gov)
3 Chris Larson, CMS Singles out Behavioral Health in Plan to Streamline Payment Across Primary Care, Specialty Care, Behavioral Health Business (Jan. 5, 2023) Business (bhbusiness.com)
4 Faridat Animashaun, CMS Updates Guidance for Coverage of Interprofessional Consultation, America’s Essential Hospitals (9 Jan. 2023) CMS Updates Guidance for Coverage of Interprofessional Consultation – America’s Essential Hospitals
5 Centers for Medicare & Medicaid Services, Coverage and Payment Interprofessional Consultation in Medicaid and the Children’s Health Insurance Program (CHIP) (January 5, 2023) *SHO 23-001 – Interprofessional Consultation (medicaid.gov)
6 ID card.
7 ID card.
8 ID card.
9 ID card.
10 Dahlke, S., Hunter, K., Reshef Kalogirou, M., Negrin, K., Fox, M., & Wagg, A., Perspectives about Interprofessional Collaboration and Patient-Centred Care, Canadian Journal on Aging / La Revue Canadienne Du Vieillissement, 39(3), 443-455 (2020) doi:10.1017/S0714980819000539; Will O’Connor, 5 Benefits of Interprofessional Collaboration in Healthcare, TigerConnect (Nov 4, 2019) 5 Benefits of Interprofessional Collaboration in Healthcare | TigerConnect
11 Centers for Medicare & Medicaid Services, Coverage and Payment Interprofessional Consultation in Medicaid and the Children’s Health Insurance Program (CHIP) (Jan. 5, 2023) *SHO 23-001 – Interprofessional Consultation (medicaid.gov)
12 Potential Economic Impact of Integrated Medical-Behavioral Healthcare, Milliman Research Report (Jan. 2018) https://www.milliman.com//media/milliman/importedfiles/uploadedfiles/insight/2018/potentialeconomic-impact-integrated-healthcare . ashx.
13 Interprofessional Consultation: Choosing a Patient-Centered Referral, Comagine Health, Interprofessional Consultation: Choosing a Patient-Centered Referral (nrtrc.org)
14 Centers for Medicare & Medicaid Services, Coverage and Payment Interprofessional Consultation in Medicaid and the Children’s Health Insurance Program (CHIP) (Jan. 5, 2023) *SHO 23-001 – Interprofessional Consultation (medicaid.gov)
15 ID card.
16 ID card.
17 See Roby, DH and Jones EE, Limits on Same-day Billing in Medicaid Participants Instruction of Behavioral Health into the Medical Home Model, Psychological Services, Vol. 13, No. 1 (2016) https://doi.org/10.1037/ser0000044.
18 Faridat Animashaun, CMS Updates Guidance for Coverage of Interprofessional Consultation, America’s Essential Hospitals (9 Jan. 2023) CMS Updates Guidance for Coverage of Interprofessional Consultation – America’s Essential Hospitals
The content of this article is intended to provide a general guide to the topic. Expert advice should be sought regarding your particular circumstances.
