When a long-time patient recovered from COVID and visited Dr. William Sawyer’s office, the conversation quickly changed from coronavirus to anxiety and ADHD.
Sawyer, who has been practicing family medicine for over 30 years in the Cincinnati region, asks questions about patients’ exercise and sleep habits, counseling about breathing techniques, and 30 minutes to prescribe attention deficit / hyperactivity disorder. Said spent. Disability medicine.
At the end of the visit, Sawyer insured the patient with one code for obesity, one for rosacea, which is a common skin condition, one for anxiety, and one for ADHD. I submitted a request to.
A few weeks later, the insurance company sent him a letter saying he wouldn’t pay for the visit. “The services billed are for the treatment of behavioral health conditions,” he said, and under the patient’s health plan, these benefits are covered by another company. Sawyer must file a claim against it.
But Sawyer wasn’t on the company’s network. As a result, he joined the network for physical care of the patient, but Sawyer said his recent visit claims were not completely covered. And it will be passed on to the patient.
Concerns about mental health have increased over the past decade and reached new heights during the pandemic, requiring primary care physicians to provide mental health care. Studies show that primary care physicians can treat patients with mild to moderate depression as well as psychiatrists. This can help address the national shortage of mental health providers. Primary care physicians are also likely to contact patients in rural areas and other poorly serviced areas and are trusted by Americans across political and geographic boundaries.
However, the way many insurance plans cover mental health does not necessarily support integrating it with physical care.
In the 1980s, many insurers began adopting what is known as a behavioral health carve-out. In this model, health insurance contracts with other companies to provide members with mental health benefits. Policy experts say the goal is to keep costs down and allow companies with mental health expertise to manage their profits.
However, over time, the model separates physical and mental health care, forcing the patient to navigate two sets of rules and a network of two providers to deal with double the complexity. Concerned.
Patients usually don’t even know if their insurance plan has a carve out until the problem occurs. In some cases, major insurance plans may reject a claim because it is related to mental health, but behavioral health care companies also reject it because it is physical.
Jennifer Snow, Head of Government Relations and Policy for the National Mental Illness Family Alliance, an advocacy group, said: She said the patients did not receive the overall care most likely to help them and they may end up with a self-paying invoice.
There is little data on how often this scenario (the patient receiving such invoices or the primary care physician is not paid for mental health services) occurs. However, Dr. Sterling Lanson, Jr., president of the American Academy of Family Physiology, said he has received “more and more reports” about the pandemic since it began.
Even before COVID, studies show that primary care physicians treated almost 40% of all visits for depression or anxiety and prescribed half of all antidepressants and anxiolytics.
Now, with the psychological stress of a two-year pandemic, “more office visits are due to concerns about anxiety and depression,” Lanson said.
This means that your doctor is using your mental health code to file more claims. This increases the chances of refusal. Your doctor can either file these denials or try to recover your payment from the carve-out plan. However, in a recent email discussion between family doctors later shared with KHN, doctors with their own practice with little administrative support spent time on paperwork and phone calls to sue for refusal. Said it would cost more than the final refund.
At some point, California’s family doctor, Dr. Peter Leapman, told KHN that he had completely stopped using psychiatric diagnostic codes in complaints. When he saw a patient with depression, he coded it as fatigue. Anxiety was coded as palpitation. He said it was the only way to get paid.
In Ohio, Sawyer and his staff decided to sue insurance company Anthem instead of handing the invoice to the patient. They asked Anthem by phone or email why claims for treatment of obesity, rosacea, anxiety, and ADHD were denied. About two weeks later, Anthem agreed to refund the visit to Sawyer. The company didn’t provide an explanation for the change, Sawyer said, wondering if that would happen again. If so, he doesn’t know if the $ 87 refund is worth the hassle.
“Everyone in the country is talking about integrating physical and mental health,” Sawyer said. “But if we aren’t paid to do it, we can’t do it.”
In a statement to KHN, Anthem spokesman Eric Lail said that KHN regularly with clinicians who provide mental and physical health care to provide accurate codes and receive appropriate refunds. He said he was cooperating. He wrote that the provider of concern can follow the standard appeal process.
Kate Berry, senior vice president of clinical practice at AHIP, an industry group of insurers, said many insurers are working on ways to support patients receiving mental health care in their primary care offices. Explain the appropriate billing code to use for integrative medicine.
“But not all primary care providers are ready to accept this,” she said.
According to a 2021 report from the Washington, DC think tank, Bipartisan Policy Center, some GPs combine mental and physical care in their practice, but “many doctors have training, funding, guidance, and more. And lacks staff. ”
Richard Frank, Co-Chair of the Task Force that published the report and Director of the Blue Kings Schaefer Initiative on Health Policy at the University of Southern California, said: “Many primary care physicians dislike the treatment of depression.” They may find it outside the scope of their expertise or may take too long.
One study focused on older patients found that some family doctors changed subjects when patients developed anxiety and depression, and typical mental health discussions lasted only two minutes. I did.
Doctors have pointed out underpayment as a problem, Frank said, “exaggerating how often this happens.” Over the last decade, he said, billing codes have been created to allow primary care physicians to charge for integrated physical and mental health services.
Still, the division will continue.
One solution is for the insurer or employer to end the behavioral health carve-out and provide all benefits through one company. However, policy experts say that this change could narrow the network and force patients to leave the network for care and pay at their own expense anyway.
Dr. Madukartrivedi, a psychiatrist at the University of Texas Southwestern Medical Center who often trains primary care physicians to treat depression, summarizes integrated care in “Chicken and Egg Problems.” Said. Doctors say they provide mental health care if the insurance company pays, and insurance companies say they pay mental health care if the doctor provides the right care.
Again, the patient loses.
“Most of them don’t want to be shipped to professionals,” Trivedy said. Therefore, if you do not receive mental health care from your doctor, you often do not receive it at all. Some people wait until a crisis situation is reached before arriving at the emergency room. There is growing concern, especially for children and teens.
“Everything is delayed,” Trivedy said. “That’s why there are more crises, more suicides. There is a price to be paid for not being diagnosed or getting proper treatment early.”
KHN (Kaiser Health News) is a national news room that produces detailed journalism on health issues. KHN is one of the three main operational programs of KFF (Kaiser Family Foundation), along with policy analysis and polling. KFF is a donated non-profit organization that provides the public with information on health issues.
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