A Machiavellian win for the NYS Early Intervention Program

Well I believe in equal opportunity blogging so when NYS does something correct with the early intervention program I have to herald the effort.

On August 17 Governor Cuomo signed a bill that facilitates payment of claims by health insurers to municipalities for early intervention services.

In a previous blog post I talked about the 85% denial rate that exists because the state government doesn't know how to collect from private insurance companies. This new law causes the IFSP to meet any precertification, preauthorization and medical necessity requirements imposed on benefits under any insurance policy.

There are additional new rules that prohibit insurers from denying claims based on the location where services are provided, the duration of the child's condition or that the child's condition is not likely to improve within a time specified in the policy, the absence of a referral by a primary care provider, or that the provider is a non-participating or non-network provider.

I would prefer that municipalities simply bill the same way that I do in my private practice. It would save a lot of time and hand-wringing about having to codify this into law and make excuses for government ineptitude.

Imagine if private practice billing could be made so easy with the stroke of a pen! Although this is ultimately good, it is also a lesson in how ridiculous it is that the government, being unable to play by the rules that everyone else on the planet are subject to, decides that the rules don't apply if they are playing. Hilarious.

Maybe I should try a letter like this:

Dear NY State:

The mean insurance company won't pay me because I don't like to follow the rules. I don't want to be a participating provider, I don't want to be subject to their timely filing requirements, and I don't want to answer to any of their demands. Therefore, please make them suspend all the rules for me - just like they did for you.

Do you think that would work?

Anyway, despite the hilarity of it all, it really is a good thing because the EIP will exist longer into the future if it is able to recoup money from insurance companies. This is NOT a new mandate - the insurance companies just got really good at denying EIP claims because no one in the EIP system knows about medical billing. Now the heavy handed government is going to make them pay whether they follow the rules of proper billing or not. I guess the Prince felt that he had to defend his State, blah blah blah. I know, I don't like the means either. Sigh.

Oddly, the United EI Providers Group made a little noise about this bill and lobbied people to try to stop it. As I mentioned before, I respect that they object to reforming EIP on the backs of providers but I think their analysis of this issue is as sharp as a marble. This law has nothing to do with direct access and it won't change all that much on the practice side of things and it is not a cleverly concealed stimulus program for primary care providers - so in total I just don't get the objections. Oh well.

So this was a good thing for the Early Intervention Program, even if it was a little Machiavellian.


Leslie Grubler said…
Chris --
Although it appears that this legislation is simply focused on enabling Early Intervention to be reimbursed, the language of the bill-now-law does not limit the changes to Early Intervention -- it impacts "insurance law."

Our professional organizations were unaware of this legislation likely because it had been delivered to the Governor's desk on August 5th and was signed on August 17 -- a peak vacation period.

I have issued a copy of the letter that UNYEIP forwarded to Brad Hutton et al and all of our professional organizations in the hopes that the new regulations that result will not create unnecessary barriers to care. The letter should be posted on our site shortly. They are taking it seriously.
Thank you for the mentions. Aren't marbles a choking hazard anyway?
Leslie Grubler UNYEIP
Thanks for your comments Leslie.
The OT practice act bill was just signed this month and now the State Ed Department has to write the associated regs so we still have 180 days until we see anything implemented. So, there is no functional direct access for OT in NYS currently.

The new law allows direct access in non-medical situations but there probably aren't many OTs out there who would go out on a limb and state that treatment of a neurological disorder like CP or an orthopedic disorder like torticollis are not medical in nature, at least to some degree. I suppose that some kids who have generic delay because of deprivation in its various forms constitutes a non-medical or perhaps 'developmental' process but this is a very precarious slope to be walking along. Do we really want to identify ourselves as non-medical professions and give insurance companies even greater reason to decline coverage?

I understand why NYSOTA pushed the direct access piece to satisfy the desires of practitioners who work in wellness contexts but it would be quite unwise to state that this constitutes the bulk of OT practice. In truth, most OTs do provide medically related services under the direction of a physician as is required by nearly every insurance plan, Medicaid, Medicare, etc. - and the insurance systems have been very happy to pay for these effective interventions.

Anyway, it will be interesting to see how this is interpreted by State Ed in regs. They can't write regs that dismantle existing insurance law anyway so the whole direct access thing is really quite a small issue for a small number of practitioners, very few of which are in pediatrics anyway.
The broader implication though is that Medicaid reimbursement is for medically-necessary interventions, and that is why school districts and early intervention programs across the State follow the Medicaid requirements and get a physician referral to establish medical necessity. That makes direct access a little silly when it comes to schools and EIP, because I doubt that these programs around the State will be willing to give up Medicaid reimbursement just to satisfy some professionals who don't want to get a physician referral.

I certainly don't know how people all over NYS practice but up to and including today (8/23/11) any OT providing intervention in NYS requires a physician referral. I can tell you that in my geographic region OTs and PTs ALL get scripts for EI. This is not a new requirement and does not present a new barrier.

I can speak for my own profession - any OTs in NYS who have been providing EI services without a physician referral have been breaking the law.

As I mentioned in this blog post and others, we should be doing all we can to help the EIP find ways to be funded - and it would be nice if they didn't continually do that by cutting provider reimbursements. Existing insurance law ALREADY provides for EIP reimbursement so this is not a new mandate. This just makes it a little easier for EIP to collect, as outlined in this post.

There are rather large issues in front of us all as EIP practitioners - we may agree to disagree on the relevance of this law.

I encourage you to re-think your positions about opposition to 15 minute increments and now this issue with the scripts. You are objecting to a behemoth of a medical coding and billing system that has been in place for a long time and is used by EVERY health care professional in the country. The problem with EIP is not in the billing system, it is with the absolute lack of ability of the State to navigate the system, follow the existing rules, and collect payments. If private practitioners collected pennies on the dollar we would all go out of business. The State just writes laws to make it easy for itself.

We can effect change by demanding that they learn how to bill and how to collect. We can effect change by telling them that it is not good enough for them to be collecting so little on payments that if provided in a private practice would be collected without difficulty.

We probably won't effect much change by digging in our heels and objecting to the system-that-is.

Sorry for the length. Thanks again for your comments, and I'm glad you have a sense of humor about my marbles statement. I just want us all to be better educated on these issues.
Leslie Grubler said…
Thank you Chris. Excellent piece.

Let's hope we don't lose our marbles trying to get through all of this!

Sometimes we dig our heels in for reasons that are not obvious to the masses.
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