Introduction: Defining Interprofessional Consultation

In a January 5, 2023, letter to state health officials, the Centers for Medicare & Medicaid Services (“CMS”) clarified a Medicaid and Children’s Health Insurance Program (“CHIP”) policy on the coverage and payment of interprofessional consultations (the “Guidance”). An interprofessional consultation occurs when the patient’s treating physician requests the opinion and/or advice from a specialist practitioner without the patient making face-to-face contact with the specialist practitioner. The new CMS guidance clarifies that it is permissible for Medicaid and CHIP to provide reimbursement for an interprofessional consultation when the consultation is for the direct benefit of the patient without the patient’s presence.^[1]

Previous Policy: Supporting Specialist Care Consultation

CMS’ former policy did not permit coverage and payment for interprofessional consultation in the absence of the in-person presence of the patient.^[2] Instead, the treating practitioner was paid an increased payment rate to include consultation where there was a separate arrangement between the treating and consulting practitioner in place. CMS’ previous policy with respect to interprofessional consultations was considered complex and created unnecessary barriers to care.^[3] The Guidance supersedes the previous policy that prohibited interprofessional consultation coverage and payment as a distinct service since direct coverage for a specialist required face-to-face interaction with the patient.^[4]

Mechanism: Process of Coverage and Payment for Interprofessional Consultation

For interprofessional consultations to be covered by Medicaid and CHIP, the consultation itself must be for the direct benefit of the patient. The benefit incurred by the patient must be relevant to their care, and the advice from a specialized practitioner must be from the specialist’s field of expertise.^[5] In order for interprofessional consultation to be covered under Medicaid and CHIP, both the treating and consulting practitioners must be enrolled in their state as a Medicaid or CHIP provider.^[6] Given that consultation may cross state lines, the consulting practitioner must be enrolled in Medicaid or CHIP in the state where the patient resides, but consulting practitioner only needs to be licensed in the their practicing state.^[7]

Regarding the interprofessional consultation payment structure, each state has the ability to create its own reimbursement methodology for such services. Pursuant to the Guidance, CMS is creating interprofessional consultation as its own distinct service where the payment can be made directly to the consulting providers, which can be adopted independently by individual states.^[8]

Significance of Interprofessional Consultation Coverage: Improving Patient Care

The role of interprofessional consultation is to broaden access to specialty care and promote interdisciplinary contributions to patient care.^[9] Team-based patient care has proven to improve patient outcomes and safety because of a reduction in medical errors.^[10] Specialists and the treating practitioner have unique perspectives and valuable insights on the patient that lend themselves to a more comprehensive, holistic view of the patient’s care. A physician’s busy lifestyle may not allow face-to-face time with other physicians to collaborate on patient-centered care. Technology and compensation for consultation bridges the gap for increased efficiency, synergy and, corroboration. CMS has given the states expanded flexibility to utilize telehealth to deliver services and broaden availability of interprofessional consultation.^[11]

Interprofessional collaboration combats medical errors, thus creating an improved patient experience that delivers better outcomes. This results in an overall reduction in healthcare costs.^[12] With the encouragement of interprofessional consultation coverage and payment structures becoming streamlined by the CMS guidance, it is expected that interprofessional collaboration will flourish because there is increased efficiency and reduced costs for health care entities. CMS has empowered the states to have an interprofessional collaborative approach.^[13]

States’ Role in the Payment Structures of Interprofessional Consultation

States have the choice whether to pay for interprofessional consultation.^[14] If they choose to do so, they must submit a state plan amendment (“SPA”) to add a payment methodology for qualifying interprofessional consultation services.^[15] CMS strongly suggests that states review and consider CMS-established billing code and payment rates when deciding on state payment rates for similar services. As an alternative, states could also look at behavioral health integration codes that allow consultation between practitioners.^[16] States are encouraged to change or eliminate the restriction on same-day billing because it impedes the purpose of collaborative consultation and blocks the integration of patient-centered care.^[17]

Conclusion: How to Make the Guidance Work for Healthcare Entities

CMS aspires to develop and advance access to specialty care by reducing existing administrative burdens on treating practitioners.^[18] This change in direction presents states and healthcare entities with the opportunity to produce a win-win scenario that simultaneously benefits patients and providers. Based upon the Guidance, practitioners will be able to increase their use of interprofessional consultations that have the potential to improve patient outcomes while lowering overall health care costs.

FOOTNOTES

[1] Centers for Medicare & Medicaid Services, Coverage and Payment of Interprofessional Consultation in Medicaid and the Children’s Health Insurance Program (CHIP) (Jan. 5, 2023) – *SHO 23-001 – Interprofessional Consultation (medicaid.gov)

[2] Centers for Medicare & Medicaid Services, Opportunities to Design Innovative Service Delivery System for Adult with a Serious Mental Illness or Children with a Serious Emotional Disturbance (Nov. 13, 2018) Opportunities to Design Innovative Service Delivery Systems for Adults with a Serious Mental Illness or Children with a Serious Emotional Disturbance (medicaid.gov)

[3] Chris Larson, CMS Singles Out Behavioral Health in Plan to Streamline Payment Between Primary Care, Speciality Care, Behavioral Health Business (Jan. 5, 2023) CMS Singles Out Behavioral Health in Plan to Streamline Payment Between Primary Care, Speciality Care – Behavioral Health Business (bhbusiness.com)

[4] Faridat Animashaun, CMS Updates Guidance for Coverage of Interprofessional Consultation, America’s Essential Hospitals (Jan. 9, 2023) CMS Updates Guidance for Coverage of Interprofessional Consultation – America’s Essential Hospitals

[5] Centers for Medicare & Medicaid Services, Coverage and Payment of Interprofessional Consultation in Medicaid and the Children’s Health Insurance Program (CHIP) (January 5, 2023) *SHO 23-001 – Interprofessional Consultation (medicaid.gov)

[6] Id.

[7] Id.

[8] Id.

[9] Id.

[10] Dahlke, S., Hunter, K., Reshef Kalogirou, M., Negrin, K., Fox, M., & Wagg, A., Perspectives about Interprofessional Collaboration and Patient-Centred Care, Canadian Journal on Aging / La Revue Canadienne Du Vieillissement, 39(3), 443-455 (2020) doi:10.1017/S0714980819000539; Will O’Connor, 5 Benefits of Interprofessional Collaboration in Healthcare, TigerConnect (Nov. 4, 2019) 5 Benefits of Interprofessional Collaboration in Healthcare | TigerConnect

[11] Centers for Medicare & Medicaid Services, Coverage and Payment of Interprofessional Consultation in Medicaid and the Children’s Health Insurance Program (CHIP) (Jan. 5, 2023) *SHO 23-001 – Interprofessional Consultation (medicaid.gov)

[12] Potential economic impact of integrated medical-behavioral healthcare, Milliman Research Report (Jan. 2018) https://www.milliman.com//media/milliman/importedfiles/uploadedfiles/insight/2018/potentialeconomic-impact-integrated-healthcare.ashx.

[13] Interprofessional Consultation: A Patient-Centered Referral Option, Comagine Health, Interprofessional Consultation: A Patient-Centered Referral Option (nrtrc.org)

[14] Centers for Medicare & Medicaid Services, Coverage and Payment of Interprofessional Consultation in Medicaid and the Children’s Health Insurance Program (CHIP) (Jan. 5, 2023) *SHO 23-001 – Interprofessional Consultation (medicaid.gov)

[15] Id.

[16] Id.

[17] See Roby, DH and Jones EE, Limits on Same-Day Billing in Medicaid Hinders Integration of Behavioral Health into the Medical Home Model, Psychological Services, Vol. 13, No. 1 (2016) https://doi.org/10.1037/ser0000044.

[18] Faridat Animashaun, CMS Updates Guidance for Coverage of Interprofessional Consultation, America’s Essential Hospitals (Jan. 9, 2023) CMS Updates Guidance for Coverage of Interprofessional Consultation – America’s Essential Hospitals

Gabriela Garcia-Bou also contributed to this article.