New rule allows Medicaid and CHIP programs to pay specialists directly when a primary-care provider requests their advice.

New guidance issued Jan. 5 by the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) allows state Medicaid and Children’s Health Insurance Program (CHIP) programs to pay specialists directly when a primary-care provider requests their advice.

This means that specialists can be reimbursed for their care even if the patient is not present, as long as the consultation is related to their care. This new policy aims to improve access to specialty care for Medicaid and CHIP beneficiaries by allowing primary-care providers to consult with specialists more easily, thus linking routine care with specialty care. This may help more people benefit from practitioners with specialized knowledge and expertise.

Interprofessional consultations are a valuable tool for improving patient care, particularly for those with complex or chronic conditions. They occur when a primary-care provider or other qualified health professional requests advice or input from a specialist.

This can be especially important for Medicaid and CHIP beneficiaries, who may have higher rates of chronic diseases and complex health needs, and it also may help improve their health outcomes.

Achieving access to specialty care, including mental health and substance use disorder care, can be a challenge for many people. In 2019, more than 55 percent of adults with mental illnesses and nearly 35 percent of those with serious mental illnesses did not receive care, according to the National Institute of Mental Health (NIMH).

This lack of access can be particularly pronounced for certain groups, including Black, Hispanic, and other underserved communities.

Programming note: Listen to live news reports from Tim Powell every Tuesday on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.


Timothy Powell, CPA

Timothy Powell is a nationally recognized expert on regulatory matters, including the False Claims Act, Zone Program Integrity Contractor (ZPIC) audits, and U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) compliance. He is a member of the RACmonitor editorial board and a national correspondent for Monitor Mondays.

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