Has the Medicare program grown too complex to be responsive to physicians and patients? APA believes it has. Medical Director Steven M. Mirin, M.D., complained in a written statement to a House Subcommittee on Health and Environment in June that "Medicare has grown increasingly unwieldy, unresponsive, and, in many cases, hostile to physicians who provide medically necessary care to Medicare beneficiaries who are our patients."

The main problem is that the Health Care Financing Administration (HCFA) allows its 24-plus insurance carriers too much autonomy and flexibility in administering claims for outpatient visits (Part B), said Mirin.

"Patient access to identical services varies from carrier to carrier and so do documentation requirements for physicians," he observed.

Carriers often contradict Medicare coverage policy, he maintained. For example, Medicare’s carrier manual states that Alzheimer’s patients are entitled to psychiatric services. However, many carriers have routinely denied services for patients with a primary diagnosis of Alzheimer’s.

Some carriers also routinely deny claims for family therapy, another service that Medicare covers.

Mirin also expressed frustration that Medigap insurers are not paying the 50 percent copayment for outpatient psychotherapy services as required under the 1990 budget law for Medicare beneficiaries.

Mirin also addressed APA’s concerns about HCFA’s interim final rules on seclusion and restraint, noting that HCFA had arbitrarily developed the rules without the benefit of public comment or field testing. Moreover, HCFA has not yet responded to APA’s request for a cost analysis to support its assertion that complying with the interim final rules on the use of seclusion and restraint will result in minimal cost, according to the statement.

Finally, "carriers are reluctant to put information and claims interpretations, especially denial policies, in writing. Thus, physicians are forced to rely on oral statements that cannot be used to justify future claims," said Mirin.

APA recommended that HCFA make the following improvements on behalf of patients and psychiatrists:

• Conduct a systematic review of carrier operations to remove widespread variations in coverage.

• Work with local and national physician groups to identify potential problems in physician claims and develop a joint solution instead of reviewing all physician claims.

• Assess the impact of proposed rules and analyze their costs before implementing them.

• Conduct national physician education workshops on how to file claims to meet HCFA’s standards.

• Require carriers to provide physicians with understandable written explanations of coverage decisions and interpretations.

• Reduce the adversarial nature of HCFA communication with physicians.

Mike Hash, a HCFA deputy administrator, testified before the Senate subcommittee that HCFA has established an internal component, the Physicians Regulatory Issues Team, to be more responsive to physicians and ensure high-quality patient care.

The team will analyze the impact of new rules on practicing physicians before and after they are issued, survey a representative sample of physician offices about the impact of Medicare rules, and improve communication at the regional office level. The new team will also host monthly conference calls with physician groups to address current and emerging issues and upgrade the team’s Web site, <www.hcfa.gov/ medlearn>, according to Hash’s written statement.

In other Capitol Hill news, APA President Daniel Borenstein, M.D., and Clarice Kestenbaum, M.D., president of the American Academy of Child and Adolescent Psychiatry (AACAP), asked Senators Don Nickles (R-Okla.) and Judd Gregg (R-N.H.) to reconsider some of the language in the Senate-passed Patients Bill of Rights Act.

"The definition of ‘substantial harm’ is crafted in such a way that psychiatric patients could be excluded from access to the courts," stated the July 17 APA/AACAP letter.

"Substantial harm" is defined as impairment of bodily function or physical pain, which APA fears will be interpreted to exclude mental illness. The language is critical because a patient can sue a health insurer or managed care company for substantial harm resulting from a denial of a covered service if an independent reviewer approves the denial, according to the letter.

Borenstein and Kestenbaum recommended that the legislators remedy the problem by adding the phrase "mental function" to the definition of "substantial harm."