Mental health has been asked of doctors, but patients are interfering with health plans

When a longtime patient visited the office of Dr. William Sawyer after recovering from COVID-19, the conversation quickly shifted from coronavirus to anxiety and ADHD.

Sawyer, who has been practicing family medicine in Cincinnati for more than three decades, said he spent 30 minutes asking questions about exercise and sleep habits, advice on breathing exercises, and writing a prescription for attention deficit / hyperactivity disorder. disorder medications.

At the end of the visit, Sawyer filed a claim against the patient’s insurance using one code for obesity, one for rosacea, a common skin disease, and another for ADHD.

A few weeks later, the insurer sent him a letter saying he would not pay for the visit. “The billed services are for the treatment of a behavioral health condition,” the letter said, and according to the patient’s health plan, those benefits are covered by a separate company. Sawyer should file a claim.

But Sawyer was not in that company’s network. So even if the patient is in the physical care network, the claim for the last visit would not be fully covered, Sawyer said. And it would pass to the patient.

As mental health concerns have risen over the past decade, and the pandemic has reached new heights, there is a push for primary care physicians to provide mental health care. Research shows that primary care physicians can treat patients with mild or moderate depression as well as psychiatrists, which can help address the shortage of mental health providers. Primary care physicians are also likely to reach out to patients in rural areas and other underserved communities, and Americans have confidence in political and geographic divisions.

But the way many insurance plans cover mental health does not necessarily integrate care into physical care.

In the 1980s, many insurers began to take behavioral health measures. Under this model, health plans hire another company to provide mental health benefits to their members. Policy experts say the goal was to reduce costs and manage these benefits for companies that specialize in mental health.

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

Patients usually don’t know if their insurance plan has any restrictions until a problem arises. In some cases, the main insurance plan may deny a claim that it is related to mental health, and the behavioral health company may also deny that it is physical.

“It’s the patients who end up on the short end of the stick,” said Jennifer Snow, head of government relations and policy for the National Alliance on Mental Illness, a advocacy group. Patients do not receive comprehensive care that will provide them with support, and may have a pocket bill, he said.

There is little data to show how often this scenario occurs: such as what patients who receive these bills or primary care physicians do not pay for mental health services. But Sterling Ransone Jr., president of the American Academy of Family Physicians, said he has been receiving “more and more reports” about it since the pandemic began.

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

With the additional mental stress of the two-year-old pandemic now, “we are seeing more visits to our offices worrying about anxiety, depression and more,” Ranson said.

This means that doctors send more claims with mental health codes, which creates more opportunities for denial. Doctors can appeal these denials or try to charge you for a payment split plan. But in a recent email discussion between family doctors, which was later shared with Kaiser Health News, those who do their own practice with little administrative support said the time spent in appeals and phone calls to deny denials costs more than the final refund.

Peter Liepmann, a family physician in California, told KHN that he had stopped using psychiatric diagnostic codes at some point in his claims. If he saw a patient with depression, he coded it as fatigue. Anxiety was coded as palpitations. That was the only way to pay for it, he said.

In Ohio, Sawyer and his staff decided to turn to Anthem insurer instead of passing the bill to the patient. In calls and emails, Anthem has been asked why she has been denied a claim to treat obesity, rosacea, anxiety and ADHD. About two weeks later, Anthem agreed to return the visit to Sawyer. The company did not comment on the change, Sawyer said, wondering if it would happen again. If he does, he’s not sure it’s worth the $ 87 refund.

“He’s talking about integrating physical and mental health across the country,” Sawyer said. “But if they don’t pay us to do that, we can’t do it.”

Eric Lail, a spokesman for Anthem, said in a statement that the company regularly works with physicians who send accurate and properly paid mental and physical health codes. Concerned providers may follow the standard appeals process, he wrote.

Kate Berry, AHIP, vice president of clinical affairs for an insurance trading group, said many insurers are working on ways to help patients receiving mental health care in primary care offices; for example, explaining to doctors how to use standardized training tools and the appropriate billing codes to be used for comprehensive care.

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

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

Richard Frank, co-chair of the report and director of the University of Southern California-Brookings Schaeffer Initiative on Health Policy, said: “Many primary care physicians do not like to treat depression. ”They may think that it is out of their specialization or that it takes too much time.

A study of elderly patients found that some primary care physicians change the subject when patients experience anxiety or depression and that the usual mental health discussion lasts only two minutes.

Doctors point out that the problem is a lack of payment, Frank said, but they are saying “this is an abuse that happens so often.” Over the past decade, billing codes have been created to allow primary care physicians to charge for integrated physical and mental health services, he said.

However the division persists.

One solution could be for insurance companies or employers to end their behavioral health restrictions and provide all the benefits through a company. But policy experts say the change could lead to tight networks, which could force patients to withdraw from the network for care and still pay out of pocket.

Madhukar Trivedi, a psychiatrist at Texas Southwestern Medical Center in Texas who often trains primary care physicians to treat depression, said integrated care is “a chicken and egg problem.” Doctors say they will provide mental health care if insurers pay for it, and insurers say they will pay if doctors provide proper care.

Patients, on the other hand, lose out.

“Most people don’t want to be referred to specialists,” Trivedi said. So when they can’t get mental health care from the first doctor, they often don’t get it at all. Some wait until they reach a crisis point and end up in an emergency room – especially for children and teenagers.

“Everything is delayed,” Trivedi said. “That’s why there are more crises, more suicides. There is a price for not getting the diagnosis or getting the right treatment early. “

Kaiser Health News is a national newsroom that deals with health issues.

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