Interprofessional Consultation Payments
Female doctor in office
Coverage of Interprofessional Consultations and the Impact on Providers and Patients
Background
Interprofessional consultation occurs when one health care provider requests the opinion or advice of another health care provider with particular expertise to assist in the treatment of a patient. Longstanding CMS policy, most recently described in 2018, was that a health care provider could only be paid for a service if the beneficiary was present, this included interprofessional consultations. As a result, it was not possible to pay a consulting provider if they were not present with the patient at the time of service.
CMS now clarifies its policy regarding interprofessional consultations. A consulting provider no longer needs to be present in order to receive payment for that service. This brings Medicaid and Children’s Health Insurance Program (CHIP) policy in line with Medicare.
For example, if a primary care provider (PCP) needs to have a same day urology consultation, both the PCP and urologist can now be paid for their time consulting on the client’s care. Within behavioral health services, providers may now be able to participate in treatment planning (such as Child and Family Teams) or care transition meetings, for which they would not have received payment prior to this policy change.
Potential to Increase Access and Quality of Care
According to CMS, timely access to specialty care can “improve the quality of care and treatment outcomes for both physical and behavioral health.”
This shift in policy has the potential to impact patient care in a variety of ways. Those in need of behavioral health services, in particular, have difficulty accessing such services. Geography is also a factor in access to specialty care as individuals residing in rural areas face a shortage of providers.
Additionally, interprofessional consultation has been championed by the World Health Organization, and is a key component of many collaborative care and health home models.
The ability for Medicaid and CHIP providers to receive payment for interprofessional services can theoretically allow for more of those services which, in turn, could yield greater health care access, reduce long term health care costs, and achieve better outcomes.
Additional Benefits
-
Reduces clinical, medical, and medication errors
Reduces duplication of services or efforts
Expands access to specialist providers (e.g., substance use providers, behavioral health providers, allied health professionals) to address complex care needs
Accelerates initiation of treatment, clarification of health care needs, and alignment with level of acuity
-
Enhances participation, coordination, and integration across systems and specialties (e.g., social services and foster care providers, school-based providers, intellectual disability providers) in treatment planning, implementation, and discharge/transition planning
Improves provider decision-making
Improves client/patient satisfaction
-
Improves client/patient engagement and retention (in particular, for more disengaged populations such as individuals with a substance use disorder condition, homelessness or veterans)
Supports a recovery focus to help maintain individuals in their home and community, and minimize the reliance on emergency room or other acute settings
Reduces health care costs
Important next steps for state Medicaid programs
If a Medicaid program wants to pay for interprofessional consultations, a State Plan Amendment that details a payment methodology is required. CMS says that states have flexibility when designing the payment methodology, but it also encourages states to consider the bill codes and payment rates established under Medicare. Additionally, CMS encourages states to consider removal of prohibitions on same-day billing, which might impede interprofessional consultations.
States should be cognizant that, as with any other service, there must be claiming mechanisms that appropriately document interprofessional consultation services.