Persistent psychologist wins change in Medicare regulation

By Paula Hartman-Stein, Ph.D.

  The prospect of changing a Medicare reimbursement regulation may appear to be mission impossible, but one California psychologist accepted the tough challenge with remarkable results. Joseph Casciani, Ph.D., President of San Diego based Vericare, a company that provides psychological and psychiatric coverage to long- term care facilities, fought the policy of a California Medicare carrier, National Heritage Insurance Company (NHIC), that restricted health and behavior interventions to two hours of treatment per year for any medical condition. Largely as a result of Casciani’s advocacy efforts, National Heritage announced that as of January 1st it will reimburse health and behavior interventions for its California beneficiaries for one hour of assessment and up to12 hours or 48 units of treatment sessions per year. 

“All I can say is that some you win and some you lose. This was a win,” according to Casciani. 

But the win did not come easily. 

In June 2004 the Medicare carrier opened its comment period for their policy on Health and Behavior (H and B) services restricting services to two hours or eight fifteen minute units of service per year. Casciani responded with a strong letter objecting to the severe restriction of allowable service. NHIC essentially ignored his initial comments, adopting the limited benefit. “It was the same policy NHIC established in their New England states in 2003,” said Casciani, based upon the notion that two hours met a national average of treatment sessions for these services. “We had done some tracking, and our length of treatment averaged between 12 to 15 hours per year.”

Casciani began a three month long process of advocacy effort beginning with a face to face meeting with Dr. Bruce Quinn, the Carrier’s Medical director, along with Charles Faltz, Ph.D. Director of Professional Affairs from the California Psychological Association.

  “The Medical director was very reasonable, and receptive to input and arguments on the benefits of these codes with the nursing home population,” according to Casciani.  

  The director had asked for specific case material and treatment templates. Casciani supplied him with clinical examples such as a 51- year old patient with amyotrophic lateral sclerosis who requested additional nursing care due to fears of choking, an 83 year old woman with Parkinson’s disease who had refused physical therapy treatments, as well as patients with multiple sclerosis, diabetic retinopathy, and cancer.

  Casciani developed a detailed description of a multi-phase treatment for behavioral medicine cases, based upon the Prochaska Model of Change by dividing the process into assessment, rapport building, collaboration with the patient in developing a treatment plan, and a consolidation phase.

  Casciani has recently started a Behavioral Medicine program in his company. He sees psychology’s future as collaborating with physicians in providing primary health care. The Health and Behavior assessment and interventions do not focus on mental health but on the biopsychosocial factors that affect medical problems and treatments. Health and Behavior interventions are considered reasonable and necessary for the patient who has an underlying physical illness or injury and for whom the purpose is not the treatment of mental illness.  

And what about other mission impossible advocacy efforts? Casciani is now communicating with the Florida Medicare carrier, First Coast Options, one company that has rejected claims for the H and B codes.

The National Psychologist, Vol. 14, p 17  M/A/ 05

  Paula Hartman-Stein, Ph.D. is Director of Geriatric Psychology at Summa Health Systems in Akron, Ohio, and a practitioner and health care consultant at the Center for Healthy Aging in Kent, Ohio. She is past president of the APA section of clinical geropsychology. She can be reached via email at cha@en.com or her website, www.centerforhealthyaging.com.