Patients seek mental health care from their doctors, but health plans stand in the way

Patients seek mental health care from their doctors, but health plans stand in the way

When a longtime patient visited Dr. William Sawyer’s office after recovering from COVID, the conversation quickly turned from coronavirus to anxiety and ADHD.

Sawyer — who ran a family practice in the Cincinnati area for more than three decades — said he spent 30 minutes asking about the patient’s exercise and sleep habits, counseling him on breathing exercises and writing a prescription for attention deficit/hyperactivity disorder medication.

At the end of the visit, Sawyer submitted a claim to the patient’s insurance using one code for obesity, one for rosacea – a common skin condition – one for anxiety and one for ADHD.

Several weeks later, the insurer sent him a letter saying that he would not pay for the visit. “The services billed are for the treatment of a behavioral health problem,” the letter states, and under the patient’s health plan, these benefits are covered by a separate company. Sawyer should take the claim to him.

But Sawyer was not part of that company’s network. So even if he was in-network for the patient’s physical care, the claim for the recent visit would not be fully covered, Sawyer said. And that would be transmitted to the patient.

As mental health issues have increased over the past decade — and reached new heights during the pandemic — primary care physicians are pressured to provide mental health care. Research shows that primary care physicians can treat patients with mild to moderate depression just as well as psychiatrists, which could help address the national shortage of mental health care providers. Primary care physicians are also more likely to reach patients in rural areas and other underserved communities, and Americans trust them across political and geographic divides.

But the way many insurance plans cover mental health doesn’t necessarily allow it to be integrated with physical care.

In the 1980s, many insurers began to adopt what are known as behavioral health exclusions. Under this model, health plans contract with another company to provide mental health benefits to their members. Policy experts say the goal was to contain costs and allow companies with mental health expertise to manage those benefits.

Over time, however, concerns have arisen that the model separates physical and mental health care, forcing patients to navigate between two sets of rules and two provider networks and deal with twice the complexity. bigger.

Typically, patients don’t even know if their insurance plan has an exclusion until something goes wrong. In some cases, the primary insurance plan may deny a claim, saying it’s mental health-related, while the behavioral health company also denies it, saying it’s physical.

“It’s the patients who end up with the short end of the stick,” said Jennifer Snow, head of government relations and policy for the National Alliance on Mental Illness, an advocacy group. Patients aren’t getting the holistic care most likely to help them, and they could end up with a bill on their hands, she said.

There is little data to show how often this scenario – either patients receiving such bills or primary care physicians not being paid for mental health services – occurs. But Dr. Sterling Ransone Jr., president of the American Academy of Family Physicians, said he’s been getting “more and more reports” about it since the pandemic began.

Even before COVID, studies suggest that primary care physicians treated nearly 40% of all visits for depression or anxiety and prescribed half of all antidepressants and anti-anxiety medications.

Now, with the added mental stress of a two-year pandemic, “we’re seeing more visits to our offices with issues of anxiety, depression, etc.,” Ransone said.

This means doctors are submitting more claims with mental health codes, which creates more opportunities for denial. Doctors can appeal such denials or try to collect payment from the carve-out plan. But in a recent email discussion among family physicians, which was later shared with KHN, those who run their own practices with little administrative support said the time spent on paperwork and phone calls to appeal refusal was more expensive than the final reimbursement.

California family physician Dr. Peter Liepmann told KHN that at some point he stopped using psychiatric diagnosis codes in claims altogether. If he saw a patient with depression, he coded it as fatigue. Anxiety was coded as palpitations. It was the only way to get paid, he said.

In Ohio, Sawyer and his team decided to use insurer Anthem rather than pass the bill on to the patient. In calls and emails, they asked Anthem why the request for treatment for obesity, rosacea, anxiety and ADHD had been denied. About two weeks later, Anthem agreed to reimburse Sawyer for the visit. The company did not provide an explanation for the change, Sawyer said, leaving him to wonder if it will happen again. If so, he’s not sure the $87 refund is worth it.

“Everyone across the country is talking about integrating physical and mental health,” Sawyer said. “But if we’re not paid to do it, we can’t do it.”

Anthem spokesman Eric Lail said in a statement to KHN that the company routinely works with clinicians who provide mental and physical health care to submit accurate codes and obtain appropriate reimbursement. Suppliers with concerns can follow the standard appeal process, he wrote.

Kate Berry, senior vice president of clinical affairs at AHIP, a trade group for insurers, said many insurers are working on ways to support patients receiving mental health care in primary care offices – for example, teaching physicians how to use standardized screening tools and explaining the correct billing codes to use for integrated care.

“But not all primary care providers are ready to take on that,” she said.

A 2021 report from the Bipartisan Policy Center, a think tank in Washington, D.C., found that some primary care physicians combine mental and physical health care in their practices, but “many lack the training, financial resources, advice and staff” to do it.

Richard Frank, co-chair of the task force that published the report and director of the University of Southern California-Brookings Schaeffer Initiative on Health Policy, put it this way: “A lot of primary care physicians don’t like to treat depression.” They may feel like it’s beyond their area of ​​expertise or takes too much time.

A study of older patients found that some primary care physicians change the subject when patients bring up anxiety or depression, and a typical discussion about mental health lasts just two minutes.

Doctors point to lack of payment as the problem, Frank said, but they “exaggerate how often it happens.” Over the past decade, billing codes have been created to allow primary care physicians to bill for integrated physical and mental health services, he said.

Yet the split persists.

One solution might be for insurance companies or employers to end behavioral health exclusions and provide all benefits through one company. But policy experts say the change could lead to tight networks, which could force patients to go out of the network for care and pay out of pocket anyway.

Dr. Madhukar Trivedi, a professor of psychiatry at the University of Texas Southwestern Medical Center who often trains primary care physicians to treat depression, said integrated care comes down to “a chicken-and-egg problem. “. Doctors say they will provide mental health care if insurers pay for it, and insurers say they will pay for it if doctors provide the right care.

The patients, again, are the losers.

“Most of them don’t want to be sent to specialists,” Trivedi said. So when they can’t get mental health care from their GP, they often don’t get it at all. Some people wait until they have reached a crisis point and end up in the emergency room – a growing concern for children and adolescents in particular.

“Everything is delayed,” Trivedi said. “That’s why there are more crises, more suicides. There is a price to pay for not being diagnosed or receiving adequate treatment early.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and polls, KHN is one of the three main operating programs of the KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization providing information on health issues to the nation.

Copyright 2022 Florida Health News

Leave a Comment

Your email address will not be published.