Increased Coverage of Interprofessional Consultations

On 5th Jan 2023, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), issued guidance that creates an easier path to specialty care for Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries. This increased coverage of interprofessional consultations allows direct payment to consulting practitioners, expanding access to specialty care and reduces the administrative burden to treating practitioners. For the first time ever, state Medicaid and CHIP programs will be able to pay specialists directly when a beneficiary’s primary healthcare provider asks for advice. For example, if a pediatrician consults with a specialty behavioral health provider about a specific patient’s needs, both providers may be reimbursed for their care, even if the patient is not present. This move ‘links’ routine care with specialty care, allowing more people to benefit from practitioners with specialized knowledge.

CMS’s previous policy prohibited coverage and payment of interprofessional consultation as a distinct service because the presence of the patient was required under that earlier policy guidance for specialty consultation services to be directly covered. Under the previous policy, the treating practitioner was paid an increased payment rate for a covered Medicaid service, which could have included costs for the consultation activities. The treating practitioner would then have to pay the consulting practitioner out of that payment rate through a separate arrangement between the two providers. This approach was administratively complex and created barriers to specialty input on beneficiary care.

This new policy will expand and expedite access to specialty care, allowing beneficiaries to benefit from experts with knowledge of their particular health condition. The new policy eliminates the need for consulting providers to coordinate payment via separate agreements with the treating practitioner, giving Medicaid and CHIP the flexibility to develop payment methods to reimburse consulting practitioners directly for their services. Importantly, these consultations can occur when the beneficiary is not physically present, ensuring personal and geographic barriers do not stand in the way of connections to care.

Defining Interprofessional Consultation

Interprofessional consultation is defined as a situation in which the patient’s treating physician or other qualified health care practitioner (i.e., treating practitioner) requests the opinion and/or treatment advice of a physician or other qualified health care practitioner with specific specialty expertise (i.e., consulting practitioner) to assist the treating practitioner with the patient’s care without patient face-to-face contact with the consulting practitioner. Interprofessional consultations are especially important for improving access to providers who specialize in child and adolescent behavioral health.

Coverage for Interprofessional Consultation in Medicaid and CHIP

To be coverable under Medicaid and CHIP, interprofessional consultation must be for the direct benefit of the beneficiary. This means 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. Interprofessional consultation is intended to expand access to specialty care and foster interdisciplinary input on patient care. It is not intended to be a replacement for direct specialty care when such care is clinically indicated.

Interprofessional consultation services may be covered under a variety of Medicaid state plan benefits, such as physician services, services of other licensed practitioners, and rehabilitative services. Regardless of the benefit, to be covered under Medicaid or CHIP, both the treating practitioner and the consulting practitioner must be enrolled in Medicaid or CHIP. For consultations that cross state lines, consulting practitioners must be enrolled Medicaid or CHIP providers in the state in which the beneficiary resides, though they need only be licensed/credentialed in the state in which they are practicing. Both the treating and consulting practitioners will be required to follow all state and federal privacy laws regarding the exchange of patient information.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete billing and coding services. We shared billing updates on increased coverage of interprofessional consultations for provider education purposes. You can email us at: info@medicalbillersandcoders.com or call us at: 888-357-3226 for billing and coding requirements.