current ethical,professional conduct & practice developments, including a review of the rules and...

Current Ethical,Professional Conduct & Practice Developments, Including A Review of the Rules and Regulations of the Board of Examiners in Psychology & Tn Law Rational to the Practice of Psychology Connie Paul, Ph.D., ABPP Memphis Center For Women & Families Executive Director, TPA Lance T. Laurence, Ph.D. Associate Professor, UT-Knoxville Director, UTK Psychological Clinic Director of Professional Affairs, TPA

TPA Convention: 11/1/12 Topics to be discussed in Part I Continuing Education for Psychology Practitioners BOE Rules & Regs on Continuing Education BOE Current Records Requirement vs. BOE Consideration of Changing Rules and Regulations Medicare: Waste/Fraud Trends per the Medicare Part D Program and Incoming Audits Torture, APA Controversy & Change in Code of Ethics Recent Tennessee Law Changes Rational to the Practice of Psychology

TPA Convention 11/1/12 Part II: ELPPP Jeopardy Your Questions Health Care Reform in Tennessee Update

TPA Convention 11/1/12 BOE Continuing Education Rule on Continuing Education: 40 hours every two years of license cycle; 18 of these must be APA Credits Type I. 3 0f these credits must be on ethics, Title 63 law, and the latest rules and regulations of the BOE Note: Reg says and rules and regulations, NOT OR. BOE HAS REAFFIRMED THIS POSITION Why this reg? Results of audits particularly changes in record requirements. BOE was finding out practitioners not aware of the latest changes in the rules and regs governing psychology practitioners. Also, new laws pass every year that effect psychology practitioners that you need to know. Question: What passed last year? Recently?

TPA Convention 11/1/12 Ethics and Rules and Regs Type III Notice from BOE in January 2012 CURRENT BOE Policy Permits practitioners to meet this licensure requirement by at least a Type III CE activity; in other words, if three of more practitioners meet to discuss THIS SECTION of the rules and regulations requirement, document the time spent and who attended, and secure signatures with dates then technically speaking, youve met this requirement. Problem: Is accurate information being shared? Quality concerns? The problem of insularity in clinical practice example from last years convention

TPA Convention 11/1/12 TPA Proposed CE Law: Type I, face-to-face activity for Ethics, Rules/Regs and Tennessee Jurisprudence Rational to the Practice of Psychology Law Withdrawn for 2012 Sparks Discussion: The Value of CE? Quality Control of Content via APA sponsorship? Access? Type of CE? Freedom-of-Choice in Ethics CEs?

TPA Convention 11/1/12 The Value of Continuing Education: is there any clinical science to support it? Does it result in actual changes in how practitioners function? What does the profession think of continuing education activities? Quality Control Issues: APA Sponsorship or Not? Why TPA Uses the APA Model for CE activity. Access/Type: Where? Size? Type of Format? Freedom of Choice Issues: Some want no mandate on the type of CE activity vs others (BOE considering requiring annual diversity requirements)

The Value & Clinical Science of CE Goal of Continuing Education: lifelong learning for the profession and the ability to actually impact how we understand and treat our patients. Keep current. Some doubt the effectiveness of CE meeting the aforementioned goal. Doubters claim CE activities are a waste of time, driven by profit vs. educative motives, irrelevant and most importantly, there is no evidence Type I CEUs are more effective in promoting competence than Type II or Type III CEUs (Memphis faculty group letter 2012, colleagues in MAPA & IMPA, others not associated with professional groups)

Clinical Science of CE Are there outcome studies that support the effectiveness of CE activities meeting CE goals, be it Type I or II or III in psychology? In truth, there are no current outcome studies per se testifying to the merits of ongoing CE activity for lifelong learning/competency goals IN PSYCHOLOGY When CE put into TCA 63-11, many opposed it, particularly from Memphis (Ted May, Ph.D.). Opponents suggested periodic re-competency examinations (like M.D.s Board certified status rather than annual CE requirement; concretely, no annual CE but one undergoes another re- licensure examination every five or ten years).

Clinical Science of CE Nearly all professions require CE In psychology, as in all professions other than organized medicine, no clear outcome studies to support CE activities Outcome measures for CE in Medicine? Time for you to demonstrate your knowledge!

Audience Participation Question What do the outcome studies on CE activity in Medicine suggest?

Clinical Science of CE in Medicine Mansouri, M., Lockyer, J. A Meta-Analysis of Continuing Medical Education Effectiveness, 2007, Continuing Educ Health Prof., Winter, 27 (1) 6-15 (31 Medline Studies) Marinopoulous, et al, Agency for Healthcare Research & Quality, John Hopkins University, Pub #07-E006, January 2007, Effectiveness of Continuing Medical Education (Medline & Journal Reviews 2005-2006) Davis, et. al, Impact of Formal Continuing Medical Education: Do Conferences, Workshops, Rounds, and Other Traditional Continuing Education Activities Change Physician Behavior or Health Care Outcomes? Journal American Medical Association, Vol 282, #9, Sept 99, pp867-873 (14 studies)

Clinical Science of CE in Medicine Davis & Galbraith, Continuing Education Effect on Practice Performance, Effective of Continuing Medical Education, American College of Chest Physicians, Evidence-Based Educational Guidelines, (105 studies), 2009 Mazmanina, Davis, Galbraith, Continuing Medical Education Effect on Clinical Outcomes, American College of Chest Physicians, Evidence-Based Educational Guidelines, 2009 (37 studies, John Hopkins University Evidence-Based Practice Center) Bloom, B., Effects of continuing medical education on improving physician clinical care and patient health: A review of systematic reviews, International Journal of Technology Assessment in Health Care, 2005, 231, pp.380-385

Results of these Studies in Medicine CE does indeed make a difference High to moderate to low effect size, depending on moderator variables (i.e., passive learning, types of intervention/training, new vs. old learning, size, time) If eliminate passive learning, effect sizes across multiple studies moderate to high, particularly if active, interactive learning CONCLUSION: CE, especially using live or multiple media and multiple educational techniques, is generally effective in changing physician performance..interactive CME sessions that enhance participant activity and provide the opportunity to practice skills can effect change in professional practicemultiple exposure more effective than single exposure

Clinical Science of Psychology CE Neimeyer, Greg, Taylor, J., Wear, D., Continuing Education in Psychology: Outcomes, Evaluations & Mandates, Professional Psychology: Research & Practice, Vol 40, #6, 617-624 Neimeyer, G., Taylor, J., Wear, D., Continuing Education in Professional Psychology: Do Ethics Mandates Matter? Ethics & Behavior, 21/ (2), 165-172, 2011

Clinical Science of CE in Psychology 5,198 respondents 64.3% of those in states where Ethics mandated report getting Ethics training; 40.7% of those in states without mandates report Ethics training Ethics mandates do not effect the perceived value of ethics training those in states with mandates and without say Ethics training valuable 77.6% of 6,095 respondents in 09 study agreed or strongly agreed with mandating CE; 84.3% in those states with mandated CE. 25-30% would not likely participate in continuing education in the absence of mandated CE; so-called CE laggards

Clinical Science of CE in Psychology In their extensive review of the literature on CE in the behavioral and healthcare fields, Daniels and Walter (2002, Administration & Policy in Mental Health),bluntly concede that, outside of the field of medicine, a search revealed no controlled studies of impact of continuing education in the other behavioral health disciplines. Perhaps the most glaring omission in the current CE literature in psychology is the absence of outcome data concerning the impact of CE.In the absence of documented learning, it is more difficult still to assess the translation of that learning into practice or the impact of that learning on service delivery outcomes, such as the quality or effectiveness of psychotherapy.

Rational for TPA CE Law Drawing from Clinical Science & Self- Reports of Professional Colleagues CE valuable; even including states with no mandated CE laws, 77.6% of Psychologists self-report CE as valuable Interactive, multimedia/multi-method, face-to-face the best medium for CE activities, including more than one exposure to the material Certain folks never get CE but they treat the public and as such, it is in the publics interest for these folks to get lifelong learning, including information on the latest changes in the field as it relates to law and ethics Given the insular effect, try to influence quality control by using APA CE standard which REQUIRES PRESENTORS TO DOCUMENT THE CLINICAL SCIENCE SUPPORT FOR WHAT THEY ARE TEACHING (i.e., peer reviewed journals, books) AND TO HAVE THIS EVIDENCE REVIEWED BY AN INDEPENDENT AGENT (i.e., TPA CE Directorate/Committee)

Rationale for Proposed TPA CE Law: Current Status Bill put on hold for 2012 Discussions occurring Some concerned about access to Type I Programs and some University colleagues offended by ONLY APA Type I designation for this type of CE activity. Possible resolution: APA Type I or Type II CE Ethics & Tn. Jurisprudence rational to the practice of psychology from University-based Psychology Departments. Helps with access concerns and TPA commits to CE road show offering these types of programs

Tennessee Jurisprudence: Recent & 2012 Law Update RxP: Did not pass. 4-4 vote, new member says not this year. Keith will continue to push and hell get there! Public Chapter 218: Amends the law to provide that a restriction on the right of employed or contracted healthcare provider to practice the healthcare providers profession upon termination of employment or contract. NOW applies to Psychologists as well as O.Ds, podiatrists, chiropractors, MDs, dentists, optometrists. If you signed a non-compete, check out this law. Key: look who we are now grouped with on this law!

Current Tn. Law Public Chapter 629 Appointments to the BOE for psychologist members may be made from lists of qualified candidates furnished to the governor by interested psychology groups, including but not limited to the Tennessee Psychological Associationfor LSPEs, TPA Division of Psychological Examiners and other interested psychology groups TAPE no longer exists so needed new name Also, note no longer exclusive nominating process: true for ALL Boards, not just ours per Governors initiative

Current Tn. Law Public Chapter 75: Sign Law Started as MDs Only Doctors Law, watered down to Sign Law Yes, its true (Editorial note: how stupid!) Does not apply to LSPE or LPEs. Says Psychologists must conspicuously display copy sign of not less than one inch lettering of your name, professional degree, and immediately below your name Psychologist or doctor of philosophy. Must wear either name tag with photo I.D. for all patient encounters or communicate to the patient at the time of your lst appt. your full name and license. Subject to disciplinary action by the BOE!

Good News for LSPEs Added to T.C.A. 24 Like Psychologists, Senior Psychological Examiners can now elect to respond to a subpoena via deposition

Current Tn. Law HB 3399 by Maggart & SB 3268 by Tracy Concussion Bill: national focus Last Year: Tennessee Secondary School of Athletic Association Board of Directors voted unilaterally to adopt a policy that a Return to Play Form must be completed by an M.D., D.O., or Clinical Neuropsychologist with Concussion Training. TSSAA language accept into TMA Bill this year and will pass shortly. Major victory for Neuropsychologists and the general public!

Current Tn Law Kendras Law: Assisted outpatient treatments for those with serious mental illness (assisted means mandatory). 44 states have this lawin response to violent outcomes from those not getting follow-up care once discharged from psychiatric hospital Considerable debate regarding the calculus for executing Kendras Law and its costs Result: 10 person pilot project in Knoxville, operated by Helen Ross McNabb Center. Then revisit the issue

Current Tn Law: A& D Counselors Proponents want to set up two tier system of A & D counselors, Level I and Level II counselor Various educational requirements and scope of practice differences per designated level Level 1 practices within a treatment agency or treatment center. Level II can provide services within a treatment agency, treatment center or private practice Bill sent to summer study committee

Current Tn Law: Workers Comp TPA attempting to get Psychologists added to ability to give impairment ratings. Can do everything else, impairment ratings in some other states, but not Tennessee Deferred one year per business community, permitting coalition building for passage

Past Few Years of Legislative Activity in Tennessee Elder Abuse/Nursing Home/Criminal Background Checks Now Required For New Hires (not old hires; TPA amended that law) Changes in Child Custody Law? No, despite much interest. See LTL testimony on TPA webpage (www.tpaonline.org). Current law says best interest of the child; TPA supports this concept versus presumptive assumption of joint custody.www.tpaonline.org New Medical Records Costs Law: Can charge $20.00 for lst 5 pages, $.50 for each additional page. For DHS and SSI, must abide by old law (flat fee, $20.00). Can also charge $20.00 for affidavit to certify records released are accurate Successful Passing of Sunset of your licensing law in 2010 Sr. Psychological Examiner can now supervise Licensed Psychological Examiners and Certified Psychological Assistant Elimination of URAC/NCQA clause for TPAs UR Bill that was inserted by enemies of our bill: A Short History by LTL

TPA Convention 11/1/12 Continuing Education Compliance M.D.s: 98+% (Why?) M.D. malpractice insurance stick Percentage of Compliance for Psychology Practitioners a) 98+% (we are real doctors too) b) More than 98+% (were better than those guys) c) 80% d) 70% e) 60% f) Less than 60% Time for you to vote: which foil above?

Audience Voting Time Have you been audited lately?

TPA Convention 11/1/12 Answer is: (f) 52% (Results from 2008-2009 audit; numbers said to be rising in more recent audits to 70%+)

Rules and Regs of the BOE Why know rules and regs? Rules and regs have the force of law. Interprets, not expands the statute. Supposed to interpret the statute, not create new law Often critical interpretations emerge in rules and regs (i.e., definition of clinical psychologist, sleep as an aspect of psychological practice, RxP communications by psychology practitioners

TPA Convention 11/1/12 Board of Examiners in Psychology R/R proposed revision: Current recordkeeping rules and regulations contain nine (9) specific elements for inclusion in patient records: modalities and frequencies of treatment furnished, results of clinical tests, counseling session start and stop times, summaries of 1) diagnosis, 2)functional status, 3)treatment plan, 4) symptoms, 5) prognosis and 6) progress to date

TPA Convention 11/1/12 BOE Concerns about this recordkeeping section: APA, ASPPB, rules and regs from other states do not adopt verbatim HIPAA language Is HIPAA the best standard for what should be included in psychology records? Other components of the rules and regs seem to conflict: i.e., APA ethical standard to provide test data to the patient vs. our rule that says raw scores, notes, etc. are not included in patient records (HIPAA and state law does not have to agree)

TPA Convention 11/1/12 Recommended Change Under Review: Content All clients/patient records, or summaries thereof, produced in the course of the practice of psychology for all clients/patients shall include all information and documentation listed in TCA 63-2-101 (2)(medical records law) and such additional information necessary to insurance that a subsequent reviewing or treating psychologist, senior psychological examiner, or psychological examiner can both ascertain the nature of the services rendered and provide continuity of care for the client/patient.

TPA Convention 11/1/12 Continuing revised rule: This rule does not release the treating psychologist, senior psychological examiner or psychological examiner from need to be knowledgeable of, and comply with, stricter standards otherwise imposed by state or federal law or regulations, institutional requirements, or contractual obligations applicable to their practice.

TPA Convention 11/1/12 Continuing revised rule: 1. Client/patient records shall include, but are not limited to: (i) the name of the client/patient and other identifying information, (ii) the presenting problem (s) or purpose or diagnosis, (iii) the fee arrangement, (iv) the date and substance of each billed or service- count contact or service, (v) any test results or other evaluative results obtained and any basic test data from which they were derived, (vi) notation and results of formal consults with other providers,

TPA Convention 11/1/12 Continuing revised rule: (vii) a copy of all test and other evaluative reports prepared as component of the professional relationship, (8) any releases executed by the client/patient. 2. Not included in client/patient records are test materials such as manuals, instruments, protocols, and test questions or stimuli.

TPA Convention 11/1/12 The aforementioned rules and regulations changes in record keeping were being considered in 2009-2010, under the urging of Patrick Lavin, Ph.D., Chair Question: Which Rules on Record Keeping Do You Follow By Law? Old ones or New Proposed Ones?

Rules and Regs: Audience Vote You decide: Old or New?

TPA Convention 11/1/12 Answer: Old Ones Proposed Rules/Regulations have not yet cleared AG Review and Other Necessary Steps Some things move with the speed of a glacier

TPA Convention 11/1/12 While we are on record requirements, a reminder: Destruction of Records Requirements: Keep the entire record for seven (7) years; records for incompetent patients retained indefinitely. For minors, one year after minor turns 18 or seven (7) years from the date of the last clinical contact, whichever is longer. Shred them. When you do, the time and date and circumstances of the destruction kept for future reference.

TPA Convention 11/1/12 What if I retire? If retires or dies while in practice, patients seen in preceding eighteen (18) months shall be notified.this notification requirement shall not apply to a patient when there have been fewer than two (2) office patient encounters within the immediately preceding eighteen (18) months..copies of the records sent to

A Short Detour to a Familiar Federal Program Effecting Us All MEDICARE

Why is Medicare so important Cant I just elect to not be a Medicare provider? Yes and No: (1) How does one opt out? (2) What do you do about the next NPI number and other future developments emerging from the federal government? Hard to not deal with these people (3) How do you bill for services rendered if you have a patient that was on Blue Cross, he turns 65, and now has Medicare? Or, you have seen your now 65 year old female patient for 10 years, always self-pay. Now that she is 65, how do you bill her?

Audience Participation Time for you to answer these questions (How are you liking these audience interactive CE opportunities?)

Important Medicare Rule EVEN IF you have never taken Medicare, you MUST contact Medicare and tell them you are de-enrolling from the program (why? Probably due to your NPI #) Every two (2) years you need to write them and tell them that you continue to de-enroll as a Medicare provider You must get the patient to sign the proper form indicating they know they are responsible for your bill BEFORE you charge/bill them

Medicare Importance Population is aging and there is a great push to consolidate health care into larger treatment centers and payment systems (i.e., Dartmouths Accountable Health Plan, others). Models used for these entities will build upon what is in place for Medicare and Medicaid populations. Medicare is going to be a player in payment systems which then influences the nature and payment of future practice Commercial plans likely to try to follow cuts in Medicare with cuts in the commercial plans. Reimbursement cuts happening all over the country BCBS Fl 29%, Washington State 11%, N. Carolina 11%. Payers typically pay percentage of Medicare rate Pay for Play Incentives and Outcome Measurements already happening in Medicare and will spread to the commercial sector

Medicares Cousin: Medicaid Anti-Fraud Units Growing In 2004, $573 Million Recovered Due to Fraud In 2010, $1.85 Billion Recovered Due to Fraud Aforementioned recovered dollars resulted in 57% increase in grant money to state Medicaid Fraud Control Units (MFCUs), from $131 Million to $205.5 Million Electronic Medical Records Requirement in Obama law for all who provide medical services to Medicaid & Medicare patients and 10/6/11 proposed rule requiring state MFCUs to monitor and show they are effective In Tennessee: $72 Million Recovered Due to Fraud

TPA Convention 11/1/12 Medicare OIGs April 2007 Report entitled Medicare Payments for 2003 Part B Mental Health Services: Medical Necessity, Documentation and Coding. 47% of mental health services allowed by Medicare in 2003 did not meet program requirements, resulting in $718 million in improper payments. Medicare allowed approximately $2.14 billion in 2003 for mental health services; 47% of these services did not meet Medicare requirements

TPA Convention 11/1/12 Requirements: Complete and legible Documentation of each patient encounter should include reason for encounter and relevant history; physical examination findings and prior diagnostic test results, assessment, clinical impression and diagnosis; plan for care; date and legible identity of observer; if not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred; past and present diagnoses should be accessible for treating and/or consulting physician; appropriate health risk factors should be identified; patient progress, response to changes in treatment, and revision of diagnosis documented; use of CPT code and ICD-9 th Edition should be supported by documentation in the medical record

TPA Convention 11/1/12 Errors: Upcoding, Miscoding, Lack of Documentation Upcoding: a 20-25 minute session coded as 90806 Miscoded: face-to-face time does not match coded time; no time recorded; bill one code but the documentation is for another service; place of service does not match the code; you bill an E&M code when it was another service (E&M pays higher)

TPA Convention 11/1/12 MORE MEDICARE AUDITS COMING DUE TO OIGS REPORT, BUDDING HEALTH CARE REFORM EFFORTS (eliminating 500 Billion in Waste/Fraud), AND INCENTIVES FOR AUDITORS TO FIND WASTE AND FRAUD, EVEN IF NOT THERE (9-12% Finders Fee for auditors) Healthcare Reform: Will attempt to squeeze every more savings out of Medicare from fees paid to outpatient providers. Effect: more audits Those in nursing homes and large number of Medicare patients in your caseload are major targets of auditors

TPA Convention 11/1/12 Some Dos & Donts: MUST keep Stand Alone Notes Must include date, time spent with patient, type of service, estimation of progress, specified goal(s) worked on in that session, quotes from patient said in the session, your plan and what you did, risk assessment, medication for each session. MUST for each session indicate if (1) insight-oriented Rx and nature of it or (2) CBT intervention and nature of it or (3) supportive Rx and nature of it. Clearly state how TODAYS session benefitted the patient. Make sure you have a thorough history, intake, mental status evaluation, goals, and formal individualized treatment plan for each patient.

TPA Convention 11/1/12 Dos and Donts Can you take fee-for-service on a person who has become Medicare-eligible? What about a service not covered by Medicare? Be very careful if doing nursing home work Dont bill 90806 for an patient with a Dx of Dementia. Dont miscode or upcode! NEVER CODE A MARITAL/FAMILY SESSION AS 90806 Make sure your diagnosis and interventions line up. Medicare does not like 90847 CPT Code. Expect an inquiry and need to justify the service. Often need ABN to do this service No twenty (20) person groups Get no coverage agreement for that particular service PRIOR to any service and then dont bill Medicare for it. Medicare has a specific form for this type of activity and you need to get the patient to sign it before you start rendering services. Form is called Advance Beneficiary Notice of Non-coverage (ABN) do you have it? Many in our state have had to refund money

TPA Convention 11/1/12 Underline is old and deleted; italics is kept/new: 1) From Introduction & Applicability Section (7 th paragraph, last sentence): If psychologists ethical responsibilities conflict with law, regulations or other governing legal authority, psychologists make known their commitment to this Ethics Code and take steps to resolve the conflict in a responsible manner. If the conflict is unresolvable via such means, psychologists may adhere to the requirements of the law, regulations, or other governing authority in keeping with basic principles of human rights.

TPA Convention 11/1/12 2) Ethical Standard 1.02: Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority If psychologists ethical responsibilities conflict with law, regulations or other governing authority, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. If the conflict is unreasonable via such means, psychologists may adhere to the requirements of the law, regulations or other governing legal authority. Under no circumstances may this standard be used to justify or defend violating human rights.

TPA Convention 11/1/12 3) Ethical Standard 1.03: Conflicts Between Ethics and Organizational Demands If the demands of an organization with which psychologists are affiliated or for whom they are working are in conflict with this Ethics Code, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and to the extent feasible, resolve the conflict in a way that permits adherence to the Ethics Code. take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights.

TPA Convention 11/1/12 Torture and APA Ethics Controversy Evolved from differences of opinion regarding what did or did not, should or should not, have occurred with post-911 interrogations on those thought to be terrorists and/or terrorist-connected Very passionate, angry debate. Lots of friendly-fire and accusations. Nuremberg Trials Revisited Result was change in your Code of Ethics to Ethical Standards 1.02 and 1.03, effective 6/1/10

TPA Convention 11/1/12 Carol Goodheart, Ed.D., APA President (09): These amendments are an emphatic statement that the Ethics Code does not offer a defense of the following the law or organizational demands to a charge of violating an individuals human rights See Dr. Goodheart at TPA Luncheon Friday Nov 2, 2012!

The End of Part I -Many Thanks! Part II: After The Break ELPPP Jeopardy Your Questions/Roundtable Discussion Health Care Reform in Tennessee Update

current ethical,professional conduct & practice developments, including a review of the rules and...

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