Monday Rx | February 11, 2019 | Mental Health Reimbursement Practices Threatening Patient Access
I begin by focusing on a couple of important areas often overlooked in the healthcare space.
First, recent studies showing lower reimbursement rates for mental health services may be impacting local providers and patients. Commercial and Medicare Advantage plans pay mental health providers in their networks significantly lower rates than traditional Medicare pays, which likely reduces access for patients, Congressional Budget Office analysts found.
Using claims data from the Health Care Cost Institute, the researchers found that average in-network rates for two categories of common mental health services in commercial and Medicare Advantage plans in 2014 were 13% to 14% less than fee-for-service rates in traditional Medicare.
That contrasts with the private plans paying up to 12% more than traditional Medicare for similar evaluation and management services provided by other types of physicians, according to the study published in Health Affairs. Federal and state laws require insurers to cover behavioral health services in parity with physical healthcare, but low payment rates could jeopardize those patient access gains, the authors said.
But even as private plans paid lower rates, enrollees spent more out of pocket because they went out of network for mental health services more than six times as often as for other types of services.
Other research has shown that psychiatrists and other mental health providers are significantly less likely to participate in health plan networks than other types of providers. One study found that just 55.3% of psychiatrists accepted private insurance in 2009-10, compared with 88.7% of other types of physicians, with similar sharp differences for Medicare and Medicaid.
The Health Affairs study drew on data from about 39 million plan members covered by Aetna, Humana and UnitedHealthcare, and examined seven of the 10 services most frequently delivered by mental health providers including psychiatrists, psychologists and social workers.
While commercial plans paid less than traditional Medicare for mental health services in-network, they paid far more to out-of-network providers. They spent 43% more for mental health evaluation and management services and 53% more for psychotherapy.
I would like to hear from our mental health provider members to provide some local feedback to the CBO analysis featured in national industry trade publications.
On July 1, 2017, a California law took effect that changed the way that non-contracted physicians bill and are paid for providing non-emergency care at in-network facilities including hospitals, ambulatory surgery centers and laboratories. This out-of-network billing and payment law (AB 72) was designed to reduce unexpected medical bills when patients go to an in-network facility but receive care from an out-of-network doctor.
The interim rate is the greater of the plan/insurer’s average contracted rate (ACR) or 125 percent of the Medicare fee-for-service rate for the same or similar services in the general geographic region in which the services were rendered, unless otherwise agreed to by the non-contracting provider and the payor. Both regulators have adopted a standardized methodology that all payors are required to use to compute the average contracted rate beginning January 1, 2019. For reference, the Department of Managed Health Care’s (DMHC) ACR methodology can be found on here or reach out to me and I will provide additional information.
This law includes a mechanism for physicians to challenge the payment amount if they are dissatisfied—the independent dispute resolution process (IDRP). Payors are required to participate in the IDRP once a physician begins the process.
To be eligible for IDRP a physician must first appeal in writing to the payor for additional payment. If the physician is not successful in resolving the dispute through the payor’s internal appeal process, the physician may then file an IDRP through the appropriate regulator – either DMHC or CDI, depending on the product type. Claims are only eligible for the IDRP for 365-days from the date of the payor’s written response to the appeal. If a physician attempted the appeal process but the payor was non-responsive, the 365-day limit to file IDRP will begin after 45 business days have passed from the date of receipt of the physician’s appeal.
The IDRP process for both regulators is web and email-based and conducted through the regulators’ portals, with no parallel paper process. Physicians may bundle up to 50 claims in a single IDRP application. These claims must all be for services provided by the same physician, for the same payor (health plan, insurer, or delegated entity), and for the same or similar services.
The DMHC and CDI’s IDRP processes have many differences including arbitration types, but both have fees involved that are split equally between the payor and the physician. DMHC uses traditional arbitration, meaning the arbiter can select any reimbursement amount he/she determines is appropriate. CDI uses baseball style arbitration, meaning the arbiter will select one of two the parties’ final offers and no other amount. Physicians are encouraged to utilize IDRP, as DMHC is required to consider information from the IDRP when establishing methodology for determining average contracted rates, which in turn will likely impact payor contracting practices going forward.
CMA has developed several resources to help physicians navigate this new law. These are all available, free to members, here. For more information on IDRP eligibility, identifying the regulator, the submission processes and what to include in the narrative summary justification and/or the supporting documentation, CMA has created an IDRP guide, “A Physician’s Guide to the AB 72 Independent Dispute Resolution Process,” which can be accessed by contacting me or logging into CMA’s website here.
Practices with additional questions or concerns can contact CMA’s Reimbursement Helpline at (800) 786-4262 or via email.
At LACMA, we continue to support private practice physicians as we look for ways to support physicians in groups and hospital settings as well.
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Chief Executive Officer
Los Angeles County Medical Association
“If it matters to our LACMA members, it matters to me.”
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