Patients seek mental health care from their doctor, but find health plans that stand in the way

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

Sawyer – who has led a family medicine practice in the Cincinnati area for more than three decades – said he spent 30 minutes asking questions about the patient’s exercise and sleeping habits, advising him on breathing exercises and writing a prescription for attention deficit / hyperactivity disorder. . drugs for the disorder.

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

A few weeks later, the insurer sent him a letter stating that he would not pay for the visit. “The services charged are for the treatment of behavioral health,” the letter said, and according to the patient’s health plan, these benefits are covered by a separate company. Sawyer will have to file a lawsuit before him.

But Sawyer was not in the company’s network. So, although he was on the patient’s physical care network, the request for a recent visit will not be fully covered, Sawyer said. And he would surrender to the patient.

As mental health concerns have grown over the past decade – and reached new heights during the pandemic – there is a push for 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 address the shortage of mental health providers across the country. Primary care physicians are also more likely to reach patients in rural and other underserved communities, and Americans trust them regardless of political and geographical differences.

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

In the 1980s, many insurers began adopting what is known as behavioral health care. In this model, health plans are made with another company to provide mental health benefits to its members. Policy experts say the goal was to control costs and allow companies with mental health experience to manage these benefits.

Over time, however, fears have emerged 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 twice as complex ones.

Patients usually do not even know if their insurance plan is split until a problem arises. In some cases, the basic insurance plan may deny a claim, saying it is related to mental health, while the behavioral health company also denies it, saying it is physical.

“Patients are the ones who end up with the short end of their staff,” said Jennifer Snow, head of government relations and policy at the National Alliance on Mental Illness, an advocacy group. Patients do not receive the holistic care that is likely to help them and may receive a bill out of pocket, she said.

There is little data to show how often this scenario occurs – either patients who receive such bills, or primary care physicians who remain unpaid for mental health services. But Dr. Sterling Ranson Jr., president of the American Academy of Family Physicians, said he had received “more and more reports” about it since the pandemic began.

Even before covid, according to studies, primary care physicians managed almost 40% of all visits for depression or anxiety and prescribed half of all antidepressants and anti-anxiety drugs.

After consulting a patient who had anxiety and prescribing medication for ADHD, Dr. William Sawyer, who runs a family medicine practice in Ohio, received a letter from the patient’s insurer stating that he would not pay for the visit because as per the patient’s plan is behavioral health care is provided by a separate company. (Zandra White)

Now with the added mental stress of the two-year pandemic, “we’re seeing more visits to our offices with worries about anxiety, depression and more,” Ranson said.

This means that doctors are filing more lawsuits with mental health codes, which creates more opportunities for denials. Doctors can appeal these refusals or try to collect payment from the separation plan. But in a recent email discussion with family doctors later shared with KHN, those who run their own practices with little administrative support said time spent on documents and phone calls to appeal denials cost more. from the final recovery.

Dr. Peter Lipman, a family doctor in California, told KHN that at one point he stopped using psychiatric diagnosis codes in his allegations. If he sees a patient with depression, he codes it as fatigue. Anxiety was coded as palpitations. That’s the only way to pay, he said.

In Ohio, Sawyer and his staff decided to appeal to insurer Anthem instead of transferring the patient’s bill. In calls and emails, they asked Anthem why the claim to treat obesity, rosacea, anxiety and ADHD was rejected. 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 wondering if it would happen again. If so, he’s not sure the $ 87 refund is worth the ride.

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

Anthem spokesman Eric Leil said in a statement to KHN that the company regularly works with clinicians who provide mental and physical health to provide accurate codes and receive appropriate reimbursement. 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, said many insurers are working on ways to support patients receiving mental health care in primary care settings – for example, teaching doctors how to use standardized screening tools and explaining the correct billing codes to use for integrated care.

“But not every primary care provider is willing to take this on,” she said.

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

Richard Frank, co-chair of the working group that issued the report and director of the University of Southern California-Brookings Health Policy Initiative, Schaefer, put it this way: “Many primary care physicians do not like to treat depression. They may feel that this is beyond the scope of their experience or that it takes too long.

A study focused on older patients found that some primary care physicians change the subject when patients develop anxiety or depression, and that the typical mental health discussion lasts only two minutes.

Doctors point to the lack of payment as a problem, Frank said, but they “exaggerate how often this happens.” Invoicing codes have been created over the past decade that allow primary care physicians to charge for integrated physical and mental health services, he said.

And yet the division continues.

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

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

Patients lose again.

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

“Everything is postponed,” Trivedi said. “That’s why there are more crises, more suicides. There is a cost of not being diagnosed or receiving adequate treatment early. ”

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