Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Wednesday, March 18, 2015


Guess what!

Something new is happening in New York State. Disclosure requirements for providers. Here's the scoop:

Summary of New Disclosure Requirements for Providers

New York State Public Health Law Section 24

Effective 3/31/15

Health care Professionals or Group Practice

Information to be provided in writing or on the health care professional’s website prior to the provision of non-emergency services:
·         The health care plans with which the provider participates [PHL § 24(1)].
·         The hospitals with which the health care professional is affiliated[PHL § 24(1)].

Verbal information to be provided at the time an appointment is scheduled:
·         The health care plans with which provider participates [PHL § 24(1)].
·         The hospitals with which the health care professional is affiliated[PHL § 24(1)].

Information to be provided when the Health Care Professional does not participate in the network of a patient's or prospective patient's health care plan:
·         Prior to the provision of non-emergency services, inform the patient or prospective patient that the amount or estimated amount the patient will be billed for health care services is available upon request [PHL § 24(2)(a)].
·         Upon receipt of a patient or prospective patient’s request, the amount or the estimated amount (in writing) the patient will be billed for health care services, absent unforeseen medical circumstances that may arise when the health care services are provided [PHL § 24(2)(b)].

There's more, like you need to be very specific when referring a patient to another provider, and there's stuff for hospitals, too.

This is the Emergency Medical Services and Surprise Bill, enacted because patients were seeing new doctors without realizing these doctors weren't in-network, and then getting stuck with an unexpected bill. A lot of times this happened because insurance companies have out-of-date in-network provider lists, so patients would go to someone on the list, thinking they'd be covered. Here's a link to a summary of the problem, published in 2012, An Unwelcome Surprise.

And here's an article from about a year ago, published in Families USA, New York’s New “Surprise Bill” Law Rolls out New Health Insurance Protections for Consumers , that summarizes the law. Basically:

Insurers have to keep their in-network lists up to date.

Providers need to inform patients of their network and hospital affiliations.

Providers need to tell patients they have the right to know what the bill will be like, and if the patient asks, the approximate amount, barring anything unforeseen.

You have to tell your patient how to find out how much their network will cover for any doctors you refer them to.

And analogous stuff for hospitals.

It also allows patients to get out of network care, at the expense of the insurance company, if there is no comparable inpatient care. And when there are disputes about the care that's available-like that would ever happen-these need to go through an independent review process.

And another part of the deal is that insurers need to guarantee adequate care be available in-network:

In New York, all health plans must now meet network adequacy rules to reduce the use of more expensive out-of-network medical services 

Notice that the purpose is to cut costs, not provide good care.

Notice, also, that the problem is precipitated by lack of out-of-network coverage, out of date network provider lists, and incomprehensible reimbursement rules.

So the obvious solution is to have the evil out-of-network doctors take over the responsibility of informing the patient that they're out-of-network, and figuring out how the patient can figure out what they'll be reimbursed.

I can understand how this law is helpful to patients, especially in settings like large group practices, where they get plied with impersonal bills. It has no place in a private psychiatric practice like mine. I don't have a website. I don't give new patients a clipboard with HIPAA forms and PHQ-9s and office policies in the waiting room. And I sure as shootin' won't have a bunch of legal rubes telling me how to talk to a new patient. As far as I'm concerned, therapy begins from the moment the patient picks up the phone to make an appointment. Interactions around payment are part of the treatment process, and whoever drafted the law doesn't have the training to dictate how therapy should be practiced.

Oy, so many battles. Remove Part IV of MOC, get a new certifying board, postpone e-prescribing for a year, get some out of network plans on the NY exchange. I'm exhausted. I was almost too exhausted to write this post, in fact, but then I had an idea.

What if I were to comply with this law the way contracts include unpleasant clauses, and drug ads disclose potential adverse effects? That's right, small print, and rapid, barely comprehensible speech, like on The Simpsons, in the commercial for Viagrogaine for baldness and impotence, at the end, the announcer says, "Possible-side-effects-include-loss-of-scalp-and-penis."

I participate in Federal United Care-Universal (FUC-U) plans. $17,000 per session. Rates are not guaranteed.


  1. This is amazing. I have had so many psychiatrists increase fees and even bill me retroactively at a higher fee rate with no discussion or even notice. Of all the specialists I have seen in my life, only psychiatry considers that acceptable, though it is grossly unethical and unprofessional. This should put a stop to that, or at least give a patient billed retroactively and with no discussion or even notice for hundreds of dollars some recourse.

    1. J, it's unfortunate that that happened to you, and that there was no dialogue about what you were being charged. I have to disagree with you. I don't think psychiatrists are the only doctors who would do that, and I know not all psychiatrists would do that.

    2. I did not say that all psychiatrists would do that. Mine doesn't and acknowledges it's an unethical albeit common practice amongst psychiatrists. However, I have never encountered a physician in another specialty who changes fees for a regularly scheduled (weekly, twice weekly) clinical service without notice -- and certainly not retroactively. Psychiatry unfortunately has very little oversight and is often is practiced highly unprofessional manner.

  2. And FYI - all were private practice psychiatrists who did not accept insurance. I disagree with your statement "Interactions around payment are part of the treatment process, and whoever drafted the law doesn't have the training to dictate how therapy should be practiced" - patients absolutely have the right to know the cost of their treatment prior to engaging in it. Patients also have the right to know when a fee will be raised, in advance, so that they can make an informed decision whether or not to continue with the treatment as the cost/benefit ratio may have shifted. Even when a psychiatrist is providing the best possible care, if a patient is working two jobs and still going into debt in order to pay for it, he or she has the right to decide to obtain less expensive treatment. It is not the therapist's right to decide for the patient. No other medical specialty does this.

  3. There have been some super sketchy out-of-network billing situations in New York hospitals. There was an example where the principal surgeon gets paid the contracted rate, which was pretty low, and then the assistant was out-of-network and billed $100k. The patient can't really make a decision, because he's under general.

    My guess is that the lead surgeon probably splits the money sometimes. The assistant guy was mostly doing Medicaid surgeries which pay tiny amounts of money, so a couple of $100,000 surgeries would make up for a lot.

    Except for mental health care, a New Yorker is probably safer with HMO-only coverage, because the hospital would be agreeing not to have the out-of-network guy bill separately.

    It is super frustrating, as a patient, to go into a dermatologist office to have a mole removed and to sign paperwork saying that you'll cover what the insurance won't pay and ten find out that the secretary has absolutely no idea what the procedure would cost if the insurer refused to pay.

    1. I get how that can happen. In fact, it's happened to me, as a patient. I had some minor surgery when I was in med school, at my school's hospital, covered by my school's insurance. I found out after the surgery that the anesthesia wasn't covered.

      And I understand how tempting it can be to supplement the measly reimbursement you get from medicaid with income from out of network patients, and that this can get out of control. Note that a lot of it is driven by the limitations placed on doctors by insurance companies.

      It's good that patient's have some recourse, that they can object to unfair billing and expect to be listened to.

      What I object to is the ignorance of people who tell me how to talk to my patients. It's like telling an internist that he has to draw certain labs automatically, as soon as the patient walks in the door, or he'll be in violation of some law. What if they don't need those labs? What if they need different labs? What if they're hemophiliacs? What if they don't want labs drawn?

      Patients call and ask if I take insurance. I tell them I don't. They ask what my fee is. I tell them what it is, and that I do have a sliding scale, which we can discuss in person. But the whole discussion is part of the treatment. Money is a very sensitive subject, and it has a lot of meaning, in addition to its obvious function. And its meaning varies from person to person. So if I follow a script dictated by some lawyers, it interferes with my job in getting to understand my patients.

  4. I don't give new patients a clipboard with HIPAA forms and PHQ-9s and office policies in the waiting room. And I sure as shootin' won't have a bunch of legal rubes telling me how to talk to a new patient.

    I'm not a PHQ-9 person, but don't you have a sheet of paper with consent forms and get your patients to acknowledge that you're the privacy officer. My shrink did that with an off-the-shelf form.

    1. Nope. No automatic forms. Everything gets discussed. I'm not sure what a privacy officer is. Can you enlighten me?

  5. A privacy officer is the person responsible for complying with the privacy requirements of HIPAA. In a large practice group, it will be a regular job. In a solo practice, you serve as the privacy officer, because you're responsible for complying with HIPAA.

    Here's a link to a discussion by the American Psychological Association on Practice Management and privacy practices.

    Basically, by identifying yourself as the privacy officer, you're identifying yourself as the person who is responsible for keeping your patients' records secure and that you're the person they should complain to about breaches of privacy practices. And your patients should be signing a piece of paper acknowledging that they received your privacy practices.

    From the Clinical Social Work Association's website:

    Notice of Privacy Practices (NPP)

    To insure that clients know their privacy rights, HIPAA requires practitioners to provide clients a Notice of Privacy Practices (NPP) at the time of the first session. The NPP should detail how the practitioner will treat the client's PHI and under what conditions that information will or will not be disclosed. A practitioner must maintain documentation that the client received the NPP. If for some reason, a practitioner is unable to obtain a client's signature, (s)he must document attempts to do so and the reasons why a signature was not obtained. The only time a practitioner is not required to make a good faith effort to obtain receipt of the NPP is in emergency treatment situations.

    AND (from the same website)

    Administrative Requirements-Privacy Official, Complaints and Grievances

    All covered entities must designate a privacy official who is responsible for the development and implementation of HIPAA policies and procedures as well as a contact person to receive complaints and provide further information about the covered entity's privacy practices. For solo practitioners, the practitioner themselves is the privacy official.

    1. Thanks, that was helpful. I'm not a HIPAA covered entity, so
      I don't need to do that.

    2. For now you're not, because you don't bill insurance (and there was some weird rule about billing insurance electronically), but I would watch it.

  6. You might also want to look at this from the counsel of the insurance agency of the Massachusetts Medical Society. It was updated in 2013.

    Also, it looks like the Carlat Report will sell you a sample notice, but you need to check with your State Association to make sure that New York's laws aren't stricter. Massachusetts' protections are definitely greater than the Federal ones. I could easily imagine that New York's would be too.

  7. Billing insurance electronically is the definition of HIPAA-Covered. See my post, What, Exactly, Is HIPAA? http://psychpracticemd.blogspot.com/2013/06/what-exactly-is-hipaa.html

  8. Are you also employed by a hospital part time or does a hospital retain rights over your private practice? If so, you are covered by HIPAA in all your clinical work.

    1. Nope. Not employed by a hospital in any way. Hospital has no rights. Really, I'm not a HIPAA covered entity.