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Articles: No Surprises Act clarifies patient rights &
Pharmacists can be valuable asset to treating depression {Below}

No Surprises Act clarifies patient rights

By Julie P. Jacobs, Psy.D., J.D.

The No Surprises Act (NSA), effective Jan. 1, 2022, was designed to protect patients from unexpected medical bills from out-of-network providers. Often, patients are not aware they are receiving out-of-network care and, prior to the NSA, they had little

recourse to address these unexpected bills. Although most aspects of the NSA do not apply to psychologists, many might be caught off-guard by the several sections that clearly do. Refer to The Trust’s Preliminary Guidance on the No Surprises Act for detailed information about the NSA and associated risk management considerations.

The regulation requires providers and healthcare facilities to provide written notice to all patients of their rights under the NSA. The contents of the notice vary depending on whether the care is provided at a healthcare facility or in another setting. The goal is to let patients who are self-pay or uninsured know they are protected against “surprise billing” and that they can receive a good-faith estimate (GFE) of the cost of services before they are provided. The intention is to allow patients to make informed decisions about proceeding with care based on the estimated costs. If the actual cost is significantly higher than the GFE, patients can dispute the costs through a process identified in the NSA.

Templates for the notices and the GFEs have been developed by the Centers for Medicare & Medicaid Services of the Department of Health and Human Services, and links to the templates can be found in The Trust guidance document. Using these templates as-is and altering only the areas indicated will be considered presumptive good-faith compliance with the NSA.

There is some lack of clarity regarding whether “self-pay” includes patients who are out of network but plan to submit a claim to their insurer for reimbursement. The most conservative approach is to offer the GFE to these patients until there is additional clarification. The goal is to demonstrate a good-faith attempt at compliance, and until there is further guidance, it is safer to err on the side of caution and provide the information than to fail to do so.

In addition, there is concern about how to comply with some of the GFE requirements.

For example, the GFE is expected to include a diagnosis.

However, the GFE is to be offered to new and prospective patients upon scheduling

of services before the psychologist can evaluate the patient.

Under these circumstances, using “to be determined” or ICD-10-CM diagnosis code R69

(illness unspecified) in the “diagnosis” section of the GFE is recommended.

Another challenge is estimating the course of treatment to provide a reasonable estimate of the cost of care. Given that many psychological services are ongoing in nature, it is difficult to estimate how long a course of care may be and the total costs of services. Noting this uncertainty in the GFE and providing the fee per session, indicating that the total payment will be the number of sessions multiplied by this fee, is suggested.

In addition to the notice and GFE requirements, the NSA includes requirements related to keeping provider directory listings updated. It outlines specific times when psychologists must submit correct provider directory information to insurance companies and imposes penalties for failing to keep directories updated.

The NSA is complex, and additional clarification is needed. Until then, psychologists should make a good faith effort to comply with the requirements as noted above.

Julie Jacobs, Psy.D., J.D., is an attorney and psychologist in Colorado who provides risk management consultations to psychologists insured by The Trust as well as assisting mental health providers in Colorado with setting up and maintaining their practices. Her email is: Julie.Jacobs@colorado.edu

Pharmacists can be valuable asset to treating depression

By Megan J. Ehret, PharmD, MS, BCPP

Editor’s note: At the last check, several states allow pharmacists to prescribe medications for state-specific mental health issues. Some states allow pharmacists to prescribe antidepressants and other psychotropic medications for their patients.

In the United States, the prevalence of depression symptoms has increased more than three-fold during the COVID-19 pandemic. As the number of patients with depression and other mental illnesses continues to grow, the U.S. is facing a shortage of psychiatric care providers, creating additional challenges, including reduced quality of care, low patient satisfaction, poor patient outcomes and a reduction in the workforce.

Pharmacists, beyond their dispensing roles, can play an integral part in the treatment of mental illness, including depression, and reduce the impact of the provider shortage in several practice settings. Community pharmacists working in big box, chain and independent pharmacies can assist with the treatment of depression in many different ways.

They are available to provide patient education on major depressive orders and treatments, monitor medication compliance and interactions, provide resources for increasing compliance (such as blister packs and automated refills), and monitor for adverse effects of drugs.

On average, patients visit a pharmacy 35 times a year, allowing the pharmacist to potentially create a therapeutic alliance with the patient. This regular contact allows pharmacists to identify possible changes in mood, behavior or activity, which could be signs of depression. Early identification of non-adherence to antidepressant regimens or adverse drug reactions could also help patients remain on the road to recovery. Additionally, community pharmacists can administer self-rating scales for depression, such as the PHQ-9. Community pharmacists are poised to provide recommendations and referrals for patients needing care for depression.

Approximately 1,500 pharmacists are board-certified in psychiatric pharmacy (BCPP). BCPPs have advanced knowledge and experience in the optimization of outcomes and recovery for patients with mental illness (www.bpsweb.org). With their extensive pharmacotherapy training, BCPPs represent a key resource in the management of complex patients on multiple medications.

They are trained to design, implement, monitor and modify treatment

plans for patients with mental health conditions. They are not licensed to

diagnose mental illness but are able to identify symptoms and refer patients

to other providers for services.

Clinical pharmacists within the U.S. Department of Defense and Veterans Affairs are

credentialed at the same level as nurse practitioners, allowing them to prescribe

medications and treat patients as mid-level practitioners.

In some states, collaborative practice agreements allow trained pharmacists to perform many of these functions. BCPPs also assist in the prevention of suicide by identifying symptoms, engaging in discussions with patients and developing treatment plans.

With the growing shortage of psychiatric care providers and the increasing number of individuals diagnosed with mental health disorders, each member of the healthcare community is tasked with increasing roles and responsibilities.

Pharmacists and psychologists will need to work together to increase the availability of treatment for those with mental illness. In some states and federal facilities, psychologists are currently prescribing medications. For these psychologists, pharmacists can be a key resource in medication consultation, drug interactions, monitoring the patient, identifying the lack of efficacy, side effects and recommendations for additional treatment modalities. Utilizing each professionals’ expertise will allow the team to increase productivity and increase access to much-needed healthcare.

References available from the author

Megan Ehret, PharmD, MS, BCPP, is a Professor in the Department of Pharmacy Practice and Science at the University of Maryland School of Pharmacy in Baltimore, MD. Her email is: mehret@rx.umaryland.edu