CMS announced on January 5, 2023, that Medicaid and CHIP will pay specialists who provide interprofessional consultations to other providers. Previously, CMS did not provide coverage for most interprofessional consultations because CMS required a patient to be present for the service to be covered. Now, as long as the consultation is for the “direct benefit of the beneficiary,” CMS will reimburse the consulting specialist directly even if the patient is not present during the consultation. There is also no requirement in the new guidance that the specialist interact in-person with the treating physician who requests the specialists’ consult.
The new policy also streamlines the payment for specialist consultations. The new policy simplifies the payment arrangement by reimbursing the consulting specialist directly for the consultation and reduces the administrative burden of arranging for these consulting services. Previously, the treating practitioner, in certain circumstances, would be paid a greater rate for the covered Medicaid service and then would pay the consulting practitioner a portion of that rate. This indirect compensation arrangement necessitated a separate payment arrangement between the treating practitioner and the consulting practitioner.
Providers must ensure that the consultation is for the direct benefit of the CHIP or Medicaid beneficiary for it to be covered. CMS defines this to mean that “the services must be directly relevant to the individual patient’s diagnosis and treatment, and the consulting practitioner must have specialized expertise in the particular health concerns of the patient.” CMS advises that this policy is meant to expand access to specialized care, not to replace direct interaction between a specialist and a patient when that type of treatment is clinically indicated.
CMS revised its policy to reduce Medicaid and CHIP beneficiaries’ barrier to accessing physical and behavioral health treatment. According to CMS, the COVID-19 pandemic exacerbated beneficiaries’ lack of access to specialty care. In particular, CMS noted that access to mental health and substance abuse specialists has been particularly challenging for minorities, children, and adolescents, in part due to a shortage of behavioral health providers. This provider shortage, according to CMS, has also significantly impacted beneficiaries who live in rural areas.
The new, direct payment model, which does not require face-to-face consultations with the treating practitioner or patient, allows for greater flexibility when providing care via telehealth modalities, including synchronous and asynchronous technology. Telehealth models that increase collaboration between treating providers and consulting specialists can take advantage of this new guidance. CMS made it easier for consulting specialists to provide advice to treating practitioners in part because studies have found that telehealth can increase collaboration between behavioral health specialists and primary care providers.
The CMS letter to State Health Officials regarding Coverage and Payment of Interprofessional Consultation in Medicaid and the Children’ Health Insurance Program (CHIP) dated January 5, 2023, is available here.
