Getting started with Medicaid

The second in a six-part series, this article covers issues to consider when beginning the Medicaid provider process.

By Rebecca A. Clay

Although Medicaid is a federal program, each state implements it as it sees fit, within general guidelines. “When you’ve seen one Medicaid program, you’ve seen one Medicaid program,” says Shirley Ann Higuchi, JD, associate executive director for legal and regulatory affairs in APA’s Practice Directorate.

Those variations make it crucial that you know what you’re getting into as you begin the process of becoming a Medicaid provider.

States differ in what practitioners they allow to participate, for example. Some don’t allow private practitioners to participate; others not only allow licensed psychologists but supervised interns as well. What’s covered and what codes you’re allowed to use — such as Health and Behavior codes — also differ by state. If you have a specialty, such as testing or geropsychology, be sure to investigate such issues as preauthorization and other limitations, says Robin Henderson, PsyD, chief executive for behavioral health at Providence Medical Group in Portland, Oregon. And while reimbursement rates can be generally about the same as other third-party payers’, rates vary by state, too.

Rules can differ even within states if states have one or more managed care programs in addition to regular Medicaid. (About 80 percent of Medicaid beneficiaries are now covered by Medicaid managed care programs.) Each company may have its own rules and may require providers to submit a separate application.

Finding answers to these questions can be difficult, admits Gerald Nissley, Jr., PsyD, a private practitioner in Marshall, Texas, who found his state’s Medicaid website “incredibly hard to navigate.”

Fortunately, there are plenty of resources to help you understand the process of becoming a Medicaid provider:

Take advantage of your state’s Medicaid call center. State or managed care company websites — and the provider manuals they feature — aren’t the only resource. Don’t be afraid to use the provider relations hotlines that state Medicaid programs typically offer, says Nissley. “Call centers are absolute gold,” he says. “They’re happy to walk you through things.”

Connect with your peers. “One of the best ways to get started is to reach out to other members of your state psychological association who are already Medicaid providers,” says Henderson, adding that state psychological association listservs can be a useful resource for getting questions answered. “People are always willing to step in and help.” Nissley agrees. “If I hadn’t talked to a practitioner 90 minutes away from me, I wouldn’t have known there were three managed care programs that govern Medicaid for children in eastern Texas,” he says.

Get help from APA and the APA Practice Organization. “One of the biggest member benefits we offer is consultation with our lawyers,” says Higuchi. Given the issues that Practice Organization members encounter, staff lawyers are sensitive to the legal and regulatory practice challenges faced by our members. Psychologists can also take advantage of the Practice Organization’s research, such as information on which states’ Medicaid programs allow for reimbursement of Health and Behavior codes by visiting Practice Central

As you work your way through the process, keep your eye on the ultimate prize: helping the most vulnerable, says Henderson. “Don’t give up when you get frustrated,” she says. “This population really needs your help.”