Mental Health Parity and Addiction Equity - Providers

Historically, the most common provider groups who sit outside of insurance networks include ambulance service providers, anesthesiologists, acupuncture providers, chiropractors, and behavioral health providers.  There are differing reasons for how each of these groups have developed primarily outside of the insurance network system.  Because our thoughts are different for in-network versus out-of-network providers, we will breakdown the thoughts by those categories.  Please consider that some providers could be in-network for some patients and still treat other patients who are out-of-network, so either or both sections could be applicable to you as a provider

In-Network and Out-of Network Mental Health Providers

If you are an in-network or out-of-network mental health provider (psychiatrist, psychologist, or other mental health therapist), probably the most important way in which you can support greater Mental Health Parity is to question session limitations or other limitations of coverage you feel are not appropriate for a given patient. As you likely know, one significant difficulty with the combination of mental health treatment and insurance coverage is that, in any given circumstance, there is no "normal" number of sessions  needed to treat depression, anxiety, addiction, executive function issues, obsessive-compulsive disorder, schizophrenia, etc.  As you know better than most of us, patients with the same diagnosis can require significantly different types and amounts of treatment, and that is before considering co-morbid conditions.  The barriers to obtaining exceptions to the "normal" amount of care can be incredibly time-consuming, frustrating and disheartening.  A part of your helping certain patients may involve making repeated calls, sitting on hold for long periods, filing out numerous forms, and engaging in provider-to-provider calls with providers often not even trained in mental health treatment.   We hope in the future to be in a position to provide support you, the mental health provider, as you fight for the individualized coverage needs of your patients.  Currently, the most we can do is to highlight the struggle here and to implore you to conceptualize the additional burden of seeking insurance limit extensions for those patients who require it as a central and invaluable part of the treatment process. 

In-Network Mental Health Providers

As an In-Network Provider, one of the key actions you can take to help patients trying to manage behavioral health treatment is simply to timely respond if you are not available to timely treat a patient.  It is very clear that the number of in-network mental health providers is overburdened and overwhelmed.  It would seem that the financial stressors and, maybe even more distressing, the controls insurance companies impose in making treatment decisions severely limits the availability of treatment with an in-network provider.  If you receive a call for assistance (which we all know can be the hardest and most important first step for a patient), please timely respond even if you are retired, moved, unable to take on new patients, or purely exhausted.  Your return call and maybe referrals to available in-network providers could be life-saving.  (Please do not pass on names that you do not know the availability of.  A second time failing to find help when reaching out can be devastating for patients in significant distress.)

Out-of-Network Mental Health Providers

If you are an out-of-network mental health provider (psychiatrist, psychologist, or other mental health therapist), probably the most important way in which you can support greater Mental Health Parity is to provide complete "Superbills" to you clients.  The newest insurance requirement is to require specific listing on the Superbill of both your NPI and your EIN (it was often in the past acceptable to have one or the other).  Another rejection item that is often used by insurance companies is the lack of a Place of Service (POS) code - 11 for in office and 10 for virtual.  

THOUGHT:   As mentioned in the patient section,  When dealing with out-of-network coverage and reimbursement for behavioral treatment, the insurance company will impose what is often called MAA (maximum allowable amount) or R&C (reasonable and customary) cap, which the insurance company will assert is the average or reasonable coverage price for the service provider.  This MAA/R&C amount is almost always significantly lower than the amount you as a provider are charging for the specific procedure.  The insurance company then uses their MAA/R&C amount to determine how much they will count toward the out-of-network deductible, how much they will use for their co-insurance payment calculation (once your patient has reached the out-of-network deductible amount, and even capping how much they will reimburse if your patient reaches the out-of-network, out-of-pocket maximum). This significant, "behind-the-scenes" limitation is rarely apparent or understood, but does exist.  This limit definitely affects how much your patient can obtain for reimbursement for out-of-network behavioral health services (and makes reaching the deductible seem very delayed). This information is being provided in this section, in addition to in the patient section, because it is so very important for health care parity and affordability for providers to understand often hidden, or at least unseen, barriers.  One thing providers can work with their patients on is determining (through submissions and reviewing resulting EOBs or having the patient simply calling with CPT codes in hand and asking the question) facts about their insurance company's MAAs/R&Cs.  Specifically, it is important to know the different MAAs/R&Cs for 45-minute sessions versus 50-minute sessions versus 60-minute sessions.  The MAAs/R&Cs are generally not linear and can be significantly different reimbursement amounts.  Obviously, differing times for sessions can have meaning not only in treatment plans, but also affect your own work scheduling.  However, please carefully consider how affordability for patients can too often be the difference of whether a patient can or can not continue much needed treatment.

THOUGHT FOR PSYCHIATRISTS: If you are a psychiatrist using the office visit and treatment session codes, please know that there are times when insurance companies are only reimbursing one or the other.  It has absolutely been true that some insurance companies will not reimburse both the office visit and the treatment session on the same day.  Also, be aware for any coverage discussions you may have with insurance companies that insurance companies now often refer to the office visit and treatment session as you seeing the patient twice in one day.  For your patients, you should encourage each patient to be sure on their explanation of benefits (EOB) that they are being reimbursed for both the office visit and the treatment session - not zero for one and reimbursement for only one.  (Your patients may not understand the distinction that the American Psychiatric Association created.)

ADDITIONAL THOUGHT FOR PSYCHIATRISTS:  As mentioned in the patient section,  When dealing with out-of-network coverage and reimbursement for behavioral treatment, the insurance company will impose what is often called a MAA (maximum allowable amount) or R&C (reasonable and customary) cap, which the insurance company will assert is the average or reasonable coverage price for the service provider..  This MAA/R&C amount is almost always significantly lower than the amount you as a provider are charging for the specific procedure.  The insurance company then uses their MAA/R&C amount to determine how much they will count toward the out-of-network deductible, how much they will use for their co-insurance payment calculation once your patient has reached the out-of-network deductible amount, and even capping how much they will reimbursement if your patient reaches the out-of-network, out-of-pocket maximum. This significant, "behind-the-scenes" limitation is rarely apparent or understood, but does exist.  This limit definitely affects how much your patient can obtain for reimbursement for out-of-network behavioral health services (and makes reaching the deductible seem very delayed). This information is particularly important for psychiatrists, because the breakdown of costs between office visits and treatment sessions matters depending on the MAA/RAC cap amounts your patient's insurance company chooses to impose on the office visit versus the cap amount imposed on the treatment session.  It can be frustrating, but speaking to your patient and understanding the breakdown can make the difference of whether a patient in significant need can afford treatment.

TO COME: For Both In-Network and Out-of Network Mental Health Providers

An extremely daunting and often preventative requirement of insurance companies is the request for documentation relating to behavioral health treatment.  Although information can definitely be reasonably requested as confirmation of medical necessity and treatment plan, we have an approach we believe will be helpful for both providers and their patients.  Unfortunately, we are still working on and considering the most effective approach and implementation..  We hope to help in this arena soon.  Fear of exposure and documentation should not prevent help.