Overview
The Centers for Medicare and Medicaid Services (CMS) has revised its policy guidance on the coverage and payment for interprofessional consultations under Medicaid and the Children’s Health Insurance Program (CHIP). Interprofessional consultations refer to requests by a patient’s treating practitioner for second opinions or treatment advice from a specialist practitioner. These types of services do not require face-to-face contact between the patient and the consulting practitioner. In a significant reversal from CMS’s previous policy on interprofessional consultations, CMS published a letter to state health officials in January 2023 clarifying that Medicaid and CHIP coverage and payment of interprofessional consultation is permissible, even when the beneficiary is not present, as long as the consultation is for the direct benefit of the beneficiary. The letter grants states the ability to provide coverage for interprofessional consultations, with flexibility to develop their own payment methodologies. Interprofessional consultations can expand access to specialty care, foster interdisciplinary input on patient care and reduce administrative burdens on treating practitioners.
In Depth
BACKGROUND
Since 2019, Medicare has provided separate payment for interprofessional consultations in a continuing effort to recognize a patient-centered care management model that acknowledges the value of integrating primary care and specialists to provide coordinated care to patients. In the absence of payment for interprofessional consultations, the alternative is frequently a separate patient visit with a specialist to obtain the specialist’s input. Permitting payment for these services permits a straightforward phone or internet-based consultation between a primary care practitioner and a specialist. This significantly reduces the burden on the patient, who is relieved of another appointment, and promotes integrated care.
In a similar letter to state Medicaid directors issued in November 2018, CMS prohibited the coverage and payment for interprofessional consultation in the absence of the in-person presence of the patient. Under this policy, the costs of such consultations were incorporated into the underlying rate paid to the treating practitioner for a covered Medicaid service. 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.
NEW GUIDANCE FOR COVERAGE OF INTERPROFESSIONAL CONSULTATIONS
The January 2023 letter represents a significant reversal from CMS’s previous policy on interprofessional consultations. Under the new policy, Medicaid and CHIP coverage and payment of interprofessional consultation is permissible, even when the beneficiary is not present, as long as the consultation is for the direct benefit of the beneficiary. Interprofessional consultations may be delivered in via synchronous (including audio-only) or asynchronous telehealth modalities.
The letter specifies that for an interprofessional consultation to be covered, it 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. Additionally, in order for interprofessional consultation to be covered under Medicaid or CHIP, both the treating and the consulting practitioners must be enrolled in their state as a Medicaid or CHIP provider. For consultations that cross state lines, the consulting practitioner must be enrolled in Medicaid or CHIP in the state where the beneficiary resides, but only needs to be licensed in the state in which they are practicing.
The decision whether and how to provide coverage for interprofessional consultations is ultimately up to states. Interprofessional consultation services may be covered under a variety of existing mandatory and optional Medicaid state plan benefits, with CMS suggesting that states consider a physician services, services of other licensed practitioners, rehabilitative services and health homes. States also have considerable flexibility to develop payment methodologies for interprofessional consultation services. The letter notes the similar expansion of payment for interprofessional consultations under the Medicare program, using CPT codes 99447-99449. CMS encourages states to review and consider the Medicare billing codes and payment rates for interprofessional consultations, along with behavioral health integration codes (99493, 99494, 99484), when determining state payment rates for the same services. If states choose to pay for interprofessional consultation services, they must submit a state plan amendment to add a payment methodology for the qualifying interprofessional consultation service.
As part of the coverage of interprofessional consultations, CMS encourages states to eliminate or modify prohibitions on same-day billing (the ability of a beneficiary to see more than one Medicaid provider in the same day) that may impede interprofessional consultations and prevent the integration of care between behavioral healthcare and primary care.
WHY IT MATTERS
The letter signals an important shift in CMS policy, allowing interprofessional consultation as a distinct coverable service in Medicaid and CHIP programs for which payment can be made directly to the consulting provider. Allowing direct payment to consulting practitioners expands access to specialty care, fosters interdisciplinary input on patient care and may help reduce administrative burdens on treating practitioners. This new policy aligns Medicaid and CHIP with Medicare, which has had a similar policy allowing for coverage and payment of interprofessional consultation services since 2019. States have considerable flexibility in deciding whether and how to implement coverage and payment for interprofessional consultations in their Medicaid and CHIP programs, and CMS encourages them to take advantage of this flexibility.
