Patients seek mental health care from their doctor but find health plans get in the way

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

Sawyer, who has run 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 sleep habits, advising him on breathing exercises, and write a prescription for attention deficit / hyperactivity disorder medication.

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

Several 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 states, and under the patient’s health plan, those benefits are covered by a separate company. Sawyer should have filed the complaint with him.

But Sawyer wasn’t on that company’s network. So even if he was on the net for the patient’s physical care, the complaint about the recent visit would not be fully covered, Sawyer said. And he would pass on to the patient.

As mental health problems have increased over the past decade – and reached new heights during the pandemic – there is a push for primary care doctors to provide mental health care. Research shows that primary care physicians can treat patients with mild to moderate depression as well as psychiatrists, which could help address the nationwide shortage of mental health providers. GPs are also more likely to reach patients in rural areas and other disadvantaged communities, and Americans trust them across political and geographic divides.

But the way many insurance plans cover mental health doesn’t necessarily support supplementation with physical assistance.

In the 1980s, many insurers began adopting what are known as behavioral health cuts. Under this model, health plans contract with another company to provide mental health benefits to their members. Policy experts say the goal was to keep costs down and enable companies with mental health expertise to manage those benefits.

Over time, however, concerns have emerged that the model separates physical and mental health care, forcing patients to navigate between two sets of rules and two networks of providers and facing double complexity.

Patients typically don’t even know if their insurance plan is cut until a problem arises. In some cases, the primary 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.

“It’s the patients who end up with 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 are not receiving the holistic care that is most likely to help them and could end up with an account out of their own pocket, she said.

There is little data to show how often this scenario occurs – patients receiving such bills or primary care doctors not getting paid for mental health services. But Dr. Sterling Ransone Jr., president of the American Academy of Family Physicians, said he has received “more and more reports” about it since the start of the pandemic.

Even before covid, studies suggest, primary care physicians managed nearly 40 percent of all visits for depression or anxiety and prescribed half of all antidepressants and anxiolytic medications.

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

This means doctors are filing more complaints with mental health codes, which creates more opportunities for denials. Doctors can appeal these denials or try to collect payment from the hive-off plan. But in a recent email discussion between GPs, which was later shared with KHN, those who run their own practices with little administrative support said time spent on paperwork and phone calls to appeal denials cost more than reimbursement. the final.

Dr. Peter Liepmann, a family doctor in California, told KHN that at one point he stopped using psychiatric diagnosis codes in complaints altogether. If he saw a patient depressed, he coded it as fatigue. The anxiety was coded as palpitations. That was the only way to get paid, he said.

In Ohio, Sawyer and his staff decided to turn to the insurer, Anthem, rather than transfer the account to the patient. In calls and emails, they asked Anthem why the claim for the treatment of obesity, rosacea, anxiety and ADHD was rejected. About two weeks later, Anthem agreed to reimburse Sawyer for the visit. The company has not provided an explanation for the change, Sawyer said, leaving him wondering if it will happen again. If he does, he’s not sure if the $ 87 refund is worth it.

“Everyone in the country talks about integrating physical and mental health,” Sawyer said. “But if we’re not paid to do it, we can’t do it.”

Anthem spokesperson Eric Lail said in a statement to KHN that the company regularly works with physicians who provide mental and physical health care to present accurate codes and obtain appropriate reimbursement. Problem vendors can follow the standard appeals 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 offices, such as educating doctors about how to use standardized screening tools and explaining the correct billing codes to use for integrated care.

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

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

Richard Frank, co-chair of the task force that published the report and director of the University of Southern California-Brookings Schaeffer Initiative on Health Policy, said: “Many GPs don’t like treating depression.” They may feel that it is out of their remit or takes too long.

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

Doctors point to lack of payment as the problem, Frank said, but they are “exaggerating how often this happens.” In 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 split persists.

One solution could be for insurance companies or employers to end cuts in behavioral health and deliver all the benefits through a single company. But policymakers say the change could lead to narrow networks, which could force patients out of the network for treatment and still pay out of their own pockets.

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

Patients, once again, lose.

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

“Everything is being delayed,” Trivedi said. “That’s why there are more crises, more suicides. There is a price to go undiagnosed or get adequate treatment early.”

This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorial independent news service, is a program of the Kaiser Family Foundation, a non-partisan health policy research organization not affiliated with Kaiser Permanente.

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