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Articles:  Some psychologists consider return on investment before opting into merit-based payment system & Risk Management: Touching not always a violation  {Below}


Some psychologists consider return on investment before opting into merit-based payment system

By Paula Hartman-Stein, Ph.D.

April 19, 2020

The first quality improvement system implemented by the Center for Medicare and Medicaid Services (CMS) in 2007 was designed to improve healthcare quality and reward clinicians for their efforts. The newest iteration, the Merit-Based Incentive Payment System (MIPS), has similar goals but focuses on value, not volume while saving money for CMS by making it more difficult for clinicians to obtain bonuses while raising penalties.

Large psychology practices that work in long-term care settings are likely to experience the greatest financial gains or losses.

According to a webinar created by Healthmonix, a mental and behavioral health registry that has partnered with the American Psychological Association (APA), a group of two eligible psychologists that billed Medicare $160,000 in 2019 and had used Healthmonix for reporting could gain an estimated 3 percent incentive and net an estimated return on investment of about $4,000. A group of 15 clinicians that billed Medicare $1 million in 2019 would net an approximate return on investment of more than $25,000.

Healthmonix charges approximately $314 per clinician per year to set up the system, track progress and send data to CMS. Large practices receive an undisclosed discount per provider.
Solo practitioners or those working in groups of 15 providers or less can participate in MIPS without signing up for a registry.

But Joe Casciani, Ph.D., of San Diego, who owns practices that provide psychological services in long-term care facilities, said, “MIPS becomes too cumbersome for the average practitioner, so she/he needs to sign up with a registry to do it, but the cost may become more than it’s worth.

“A few years ago, I spent hours and hours figuring out the Physicians Quality Reporting System (PQRS) to develop our rating scales and reporting criteria and found the transition period for implementing these new systems to be complicated and tedious, although I know it is important for improving healthcare.”

Not all psychologists who bill Medicare must participate in MIPS. Exemptions are possible for those who meet a low volume threshold (LVT) (treat 200 or fewer Medicare beneficiaries), bill Medicare for $90,000 or less in charges or provide 200 or fewer covered professional services. LVT psychologists will neither be penalized financially nor rewarded.

CMS allows those psychologists who fall under the criteria for the LVT to voluntarily participate in MIPS. For example, if they exceed one of the LVT criteria in 2020, such as billing for 200 or more therapy sessions, they can opt in to possibly receive a bonus in 2022.

For 2020, clinicians who are not exempt and who want to avoid a financial penalty must report six quality measures on 70 percent of all patients seen, not just Medicare patients, (up from 60 percent in 2019) and attest to engaging in improvement activities during a 90-day minimum period. Of the six measures, one must be an outcome measure or considered a high priority, such as screening for elder maltreatment.

Bonuses or penalties are based on a point system. Under that system, a clinician can accrue

100 possible points, with 85 related to quality (for using screening measures) and 15 for use

of quality improvement actions, such as collecting patient satisfaction data or documenting

improvement in care coordination.

Penalties have increased, from 4 percent in 2019 to 9 percent based on how many points accrue in 2020. To avoid the financial penalty, clinicians must earn at least 45 MIPS points overall in 2020, up from 30 points in 2019.

Nysha King, vice president of marketing and communications of Healthmonix, said the exceptional practice is defined as obtaining 85 to 100 points and is rewarded by maximum incentive payments that jumped from 4.69 percent for the 2019 performance year to 10 percent for the performance year 2020.

King said clinicians who begin in April or May to report measures and implement practice improvements would not likely be too late to meet the requirements to avoid penalties in 2022.

“These changes are just the tip of the iceberg, which make it increasingly important to have a MIPS reporting plan in place all year long to ensure thorough documentation of all necessary information,” King said.

One owner of a small group practice that provides services in long-term care facilities, who requested anonymity, said, “We do not report. After calculating the numbers we did not see the advantage from a business perspective. However, we continue to monitor many of the variables developed from the PQRS program such as pain, elder abuse, and tobacco and alcohol abuse.”

APA developed new quality measures

One criticism of prior quality reporting systems was that measures were available to psychologists that were only tangentially relevant to clinical practice. Lisa Lind, Ph.D., of San Antonio, said APA’s creation of the Mental & Behavioral Health Registry (MBHR) that has partnered with Healthmonix has filled a void for a needed resource.

Ten measures developed by an APA advisory committee for the registry are available in 2020 but only can be used by clinicians who have signed on to Healthmonix. Examples are measures involving anxiety, sleep quality and screening for Post Traumatic Stress Disorder (PTSD).

“Unfortunately, for those of us who see patients in long-term care, individuals who are permanent residents of a nursing home or who are enrolled in hospice are excluded from the two anxiety measures,” said Lind, chief of quality assurance at Deer Oaks Behavioral Health. “Given that approximately 15 percent of residents we see for psychological services have a primary diagnosis of an anxiety disorder, and given the recent trauma-informed care initiative in LTC, being able to utilize these measures would be beneficial and meaningfully useful in order to assess and track outcomes related to anxiety symptoms.”

Vaile Wright, Ph.D., director of clinical research and quality at the APA Practice Directorate and liaison to the advisory committee, said 10 psychologists from various specialty areas who were vetted by APA make up the committee. None specialize in geropsychology or work in long-term care, she said. Wright said she welcomes feedback from practitioners regarding the measures.

APA offers MIPS information to all psychologists, not just APA members, at To reach Healthmonix, go to

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Paula Hartman-Stein, Ph.D., was the chair of the first technical consulting group that developed quality measures for psychology and social work. Besides covering changes in Medicare regulations for The National Psychologist, she offers consultations to psychologists on proper Medicare documentation, advice on health and wellness programming for older adults, and leads writing workshops. She can be reached through email at

A Supportive Hug

Risk Management: Touching not always a violation

By Ofer Zur, Ph.D.

April 19, 2020

We have been told, “Don’t touch your clients!” “Minimize self-disclosure!” “Never venture outside the office with a client!” “Avoid bartering!” And, of course, “Avoid dual relationships at all costs!”

These “don’ts” and many others whisper to us as we emerge from most risk-management workshops and ethics-and-law seminars or while reading an attorney’s or (so-called) experts’ columns or blogs.

Under the guise of risk management and self-protection, we are told, Beware!

The slightest deviation from these ersatz commandments will set us on the “slippery slope” to perdition.

Risk management, the way it is often taught, means to avoid actions that may not look good in court or in licensing board hearings, regardless of their therapeutic value.

But it is possible for us to protect ourselves while preserving clinical, ethical and moral integrity. I believe we can touch clients appropriately, self-disclose when helpful, barter when necessary and appropriate, exchange gifts if it is therapeutic and engage in non-exploitative dual relationships without increasing the risk of being sued or losing our licenses.

Full guidelines are available at:

Do what it takes to help clients while ensuring that you do no harm. Show respect for them and never humiliate or exploit them or assail their dignity. Place their welfare above your fear of boards, courts, ethics committees and attorneys.

Remember you are not paid to practice defensive medicine or risk management. Your duty is to help clients with the concerns and problems they are paying you to remedy. Intervene with them according to their problems, concerns, needs, gender, personality, situation, venue, environment and culture.

Provide a safe and trusting place for healing and growth. Protect and respect client privacy and confidentiality, unless it fails to safeguard the client, community, etc., from harm or as required by the law. Intervene in the most clinically effective way, not according to dogma. Different problems often require different clinical interventions.

Do your best to avoid situations with conflicts of interest (regretfully, this is not always possible) and be aware of the standard of care in your community, often referred to as the usual and customary professional standard of practice.

Keep good records. They are extremely important from clinical, ethical, legal and risk-management points of view.

Make sure they include informed consent and office policies, initial and updated

treatment plans; records of consultations, tests, etc.; releases or authorizations to

release information; important communications to and from clients; an initial

assessment and MSE; referrals for medication evaluations, testing, and other

professionals or programs; and details about termination.

Consult with experts and educated colleagues in complex and unusual cases. Document the consultation in your clinical notes.

Several types of cases or situations merit special attention and a greater degree of caution. They include child custody, repressed or recovered memories, domestic violence and child abuse.

Types of clients and Dx who merit special attention include those with borderline personality, multiple personality or other dissociative disorders; those who are antisocial, paranoid, suicidal or homicidal, and those with a history of litigation.

Never have sexual contact or sexual relationships with current clients. Seek ethical, clinical and legal advice before entering into sexual relationships with former clients.

Handle client debt with sensitivity. Be cautious before resorting to debt collection agencies, which may trigger client complaints to licensing boards.

Practice within the limits of your expertise and scope of practice as determined by your education, supervised training and clinical experience.

Terminate thoughtfully and appropriately. ( Do not abandon clients. Offer referrals and follow-ups when appropriate. Document clearly who initiated the termination, when, the nature of the discussion and potential referrals. Summarize their treatment in records: what was and was not achieved and to what extent.

If the client terminates abruptly against your clinical judgment, send a polite letter expressing your concerns in a clinically appropriate and sensitive way. Offer to continue therapy or to refer the client to another therapist. Note that you are willing to help with the transition.

Be thoughtful about crossing boundaries, including out-of-office experiences, gifts, bartering, touch and self-disclosure. Document these interventions and, when appropriate, include them in treatment plans and ground them in a theoretical orientation.

Be thoughtful about dual relationships. ( While many forms of dual relationships are unavoidable, ethical and potentially helpful, therapy never involves sexual or exploitative business relationships. Include a statement on dual relationships in the office policies and the informed consent. Document all dual relationships, avoid those that may result in a decrease in objectivity or clinical judgment and consult on complex cases.

Pay attention to vicarious liability, such as renters or co-workers.

Finally, prevent your own burnout. Create balance in your life between professional work, familial, recreational, communal, political and/or spiritual activities.

National Psychologist CE Quiz

Ofer Zur, Ph.D., is director of the Zur Institute, an Online Continuing Education Program. He is a licensed psychologist, instructor, forensic and ethics consultant and expert witness in private psychotherapy practice in Sebastopol, Calif. His latest book (2017) is Multiple Relationships in Psychotherapy and Counseling: Unavoidable, Common and Mandatory Dual Relations in Therapy published by Routledge. His website is: https:///

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