Patients seek mental health care from their doctor but find a health plan

When a longtime patient visits Dr. William Sawyer’s office after recovering from covidosis, the conversation quickly shifts from coronavirus to anxiety and ADHD.

Sawyer – who has been running a family medicine practice in the Cincinnati area for more than three decades – said he spends 30 minutes asking questions about the patient’s exercise and sleep habits, advising on breathing exercises and writing a prescription for attention deficit / hyperactivity. Has done. Disorder medicine.

At the end of the visit, Sawyer submitted a claim for patient insurance using a code for obesity, for a rosacea – a common skin condition – for a concern, and for an ADHD.

Several weeks later, the insurer sent him a letter stating that it would not pay for the visit. The letter states, “Billed services are for the treatment of a behavioral health condition,” and under the Patient Health Plan, these benefits are covered by a separate company. Sawyer’s claim must be submitted.

But Sawyer was not on that company’s network. So even though he was on the network for the patient’s physical care, the recent visit claims would not be fully covered, Sawyer said. And it will go to the patient.

As mental health concerns have grown over the past decade – and reached new heights during the epidemic – there is a pressure on primary care physicians to provide mental health care. Research shows that primary care physicians can treat patients with mild to moderate depression, as well as psychiatrists – which can help mental health providers fill nationwide deficits. Primary care physicians are more likely to reach patients in rural areas and other disadvantaged communities, and they are trusted by Americans across political and geographical divisions.

But the way many insurance plans cover mental health does not support integration with physical care.

In the 1980s, many insurers began to adopt what is known as behavioral health engraving. Under this model, health plans contract with other companies to provide mental health benefits to their members. Policy experts say the goal was to rein in spending and allow companies with mental health expertise to operate those facilities.

Over time, however, concerns arise that the model separates physical and mental health care, forcing patients to navigate two sets of rules and two networks of providers and deal with double complications.

Patients usually do not even know if their insurance plan has an engraving until a problem arises. In some cases, the principal insurance plan may deny a claim, saying it relates to mental health, while the behavioral health organization also denies it, saying it is physical.

“It’s patients who end up with the shortest end of the stick,” said Jennifer Snow, head of government relations and policy for the National Coalition for Mental Illness, an advocacy group. Patients do not receive overall care that is more likely to help them, and they may end up with bills out of pocket, he said.

There is very little data to show how frequent this scenario is – either patients receive such bills or primary care physicians go unpaid for mental health services – happens. But Dr. Sterling Ranson Jr., president of the American Academy of Family Physicians, said he had been receiving “more reports” about the epidemic since it began.

Even before Covid, studies have shown that primary care physicians conducted about 40% of all visits for depression or anxiety and prescribed half of all antidepressant and anti-anxiety medications.

After counseling an anxious patient and prescribing ADHD medication, Dr. William Sawyer, a family medicine practitioner in Ohio, received a letter from the patient’s insurer stating that it would not pay for the visit because, under the patient’s plan, behavioral health care is a separate Is covered by the company. (Jandra White)

Now with the added stress of a two-year epidemic, “we’re seeing more visits to our office dealing with anxiety, depression and more,” Ranson said.

That means doctors are submitting more claims, including the Mental Health Code, which creates more opportunities for denial. Physicians can apply for these denials or try to raise money from the carving-out plan. But in a recent email discussion between family physicians, which was later shared with KHN, who are running their own practice with little administrative support, they say the time spent on paperwork and phone calls for an appeal denial costs more than the final compensation.

Dr. Peter Lippman, a family physician in California, told KHN that at one point he stopped using the psychiatric diagnosis code. If he sees a patient suffering from depression, he codes it as fatigue. Concerns have been coded as palpitations. That was the only way to get paid, he said.

In Ohio, Sawyer and his staff decided to apply to the insurer, Anthem, instead of passing the bill to the patient. In calls and emails, they asked Anthem why claims for treatment of obesity, rosacea, anxiety and ADHD were denied. About two weeks later, Anthem agreed to pay for a visit to Sawyer. The company did not provide an explanation for the change, Sawyer said, leaving it to wonder if it would happen again. If it does, he’s not sure $ 87 is worth the hassle.

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

Anthem spokesman Eric Lyle said in a statement to KHN that the company regularly works with physicians who provide mental and physical healthcare to submit the correct code and receive appropriate compensation. Providers 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, says many insurers are working on ways to help patients receiving mental health care in the primary care office – for example, coaching physicians and coordinators on how to use standardized screening equipment. Explain the correct billing codes to use for care.

“But not every primary care provider is ready to take it,” he said.

A 2021 report from the Bipartisan Policy Center, a think tank in Washington, D.C., found that some primary care physicians incorporated mental and physical health care into their practice, but “many lack training, funding, guidance and staff.” Do it.

The report, released by Richard Frank, a vice-president of the task force and director of the University of Southern California-Brookings Schaefer Initiative on Health Policy, put it this way: “Many primary care physicians do not like to treat depression.” They may feel that it is out of their skill range or too long.

A study focusing on elderly patients found that some primary care physicians change topics when patients bring anxiety or depression, and a general mental health discussion lasts only two minutes.

Doctors have pointed to a lack of funding as a problem, Frank said, but they are “exaggerating how often this happens.” 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.

Yet the division remains.

One solution might be to end the behavioral health engraving of insurance companies or employers and provide all benefits through a company. But policy experts say the change could narrow networks, forcing patients to go out of the network for care and pay out of pocket anyway.

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

The patient, again, loses.

“Most of them do not want to be referred to experts,” Trivedi said. So while they can’t get mental health care from their primary care physician, they often don’t get it. Some people wait until they reach a crisis point and end up in an emergency room – a growing concern, especially for children and adolescents.

“Everything is delayed,” Trivedi said. “It simply came to our notice then. There is a price to be paid for early diagnosis or inadequate treatment. ”

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