Promoting use of Level II HCPCS codes can only mean they are incredibly misinformed and clueless OR they are throwing in the towel with trying to get reimbursement and they intend on replacing skilled services with services provided by non-licensed people with 'generic' developmental training.
It seems that we have received an answer in the form of a final response to a systems complaint initiated against the NYC Department of Health and Mental Hygiene on the topic of Embedded Coaching. Click here to read that determination.
The allegation was that in NYC providers were being forced to address functional IFSP outcomes that fell outside of their scope of practice. The Department of Health's determination was that NYC was in violation of 10 NYCRR 69-4(f)(3) regarding use of individualized approaches and they were also in violation of 10 NYCRR 69-4(a)(10)(v) regarding IFSPs that meet unique needs and methodologies. As a result, NYC will need to revise its policies.
This is rather important because at the time of the email two years ago it was unclear if the recommended use of Level II HCPCS codes for developmental services would serve to pave the way for paraprofessional service delivery. The determination of the DOH is unequivocal and it seems that there is no apparent interest in a paraprofessional service delivery model, at least in terms of how they are currently interpreting these regulations about individualized approaches, scope of practice, and methodologies. It would be near impossible to square this determination with any future plan for a paraprofessional model.
What we are left with then is the alternate hypothesis that at that time of the email they had limited understanding of how Level II codes might be viewed by commercial insurance, even if they were being submitted by non-healthcare providers. It seems that this is the more likely interpretation in light of this determination letter. I understand that they at least attempted to clear the use of the Level II codes with OHIP and Medicaid, but with the way that so much Medicaid is administered through local managed care arrangements it is rather obvious that they did not really understand the complexity. The ability to recoup money from a managed care Medicaid entity using non-standard codes is questionable, even if it is the intent to write an internal rule that these services can be billed to Medicaid.
These are the kinds of complexities that gum up the billing process for service providers as well as commercial insurers. We have given feedback to PCG regarding the issue of pre-filtering so as to avoid flooding commercial insurance with non-reimbursable claims. When we talk to our local commercial insurance reps they indicate that the whole early intervention system has become a disaster precisely because of this kind of confusion.