Payment in Practice for Mental Health Care
It’s clear that integrating mental health care into a pediatric practice is good for patients and providers. But the question looms large: How do you pay for it?
Dr. Rabinowitz has fielded this question many times through his work with the AAP. (Read an interview with him in Contemporary Pediatrics and another one in Pediatric News.)
“The biggest reluctance is people are uncomfortable with how to bill,” he says. “They ask: ‘Are we doing this right? Is this illegal? Is this allowable?’”
His biggest tip for pediatricians ready to add mental health services to the practice: Don’t underestimate your ability to negotiate with insurance providers. When Parker Pediatrics first began offering mental health services they didn’t accept patients on Medicaid because of concerns about billing. But after Dr. Rabinowitz talked with the state’s Medicaid director at a conference and explained his situation, he wound up receiving written permission to bill mental health visits “incident to,” allowing payments to be processed as an extension of the physician’s work. With a billing process that adequately compensates the practice for the service they are providing, many more patients have gained access to mental health care.
“[The state director] saw the importance and saw that our program had been working,” he says. “We’ve been fortunate.”
Dr. Rabinonwitz’s experience is not necessarily an anomaly. PCC Pediatric Solutions Consultant Jan Blanchard, CPC, CPEDC, has seen communication with insurance providers yield results if it’s done in the right way.
“We spend a lot of time here at PCC convincing people that they can negotiate,” she says. “We want to give them tools and support.”
She emphasizes that the first step is to know the policies your carriers have; find your contracts and review them. And then think about why the change you’re looking to make stands to benefit the carrier as well as patients.
“Frame it in a way that can help the carrier see cost savings that is also in the best interests of the patient,” she says.
States have such vastly different requirements that it’s difficult to give blanket recommendations regarding coding for mental health, says Blanchard. She notes, however, that some CPT codes are what she called “electrified,” as in, carriers are likely to question their use if the physician isn’t licensed in a psychiatry subspecialty.
“There’s a difference between psych codes and office visit codes,” she says. “Carriers may or may not pay psych codes when the service is rendered by a clinician who is not credentialed for psych.”
Same goes for ICD-10 codes: Some may trigger review. Again, this is where knowing your contracts is important.
“If you saw a patient for suicidality and continued to see them for it, that may throw up a red flag for some carriers if you didn’t refer them to a psychiatrist or recommend that they transport to the ER or an acute care facility,” she says.
Dr. Rabinowitz says some practices may choose to credential their mental health providers through their behavioral insurance plan, which would allow the use of these psychotherapy codes for billing. But the reimbursement rate can be subpar.
“This is not a big profit maker, but you can’t do it if you’re going to lose money,” he says. “You have to at least break even and look at it as more of a benefit to your practice overall.”
Federal legislation related to mental health parity provides some protections, says Blanchard, although there are exceptions and its implementation across states varies.
Even if a provider isn’t quite ready to make the leap into integrated mental health, there are actions all pediatricians can take to support their patients’ mental health. Blanchard encourages providers to follow the AAP Bright Futures Guidelines for depression and ADHD screening beginning at 12 years old. Don’t forget to bill for that service. Same goes for post-natal depression screening: All new moms should be screened, and that service should be billed.
Appropriate screening combined with innovative approaches, like telemedicine, could help bridge the gaps in care.
“Mental health care in some areas is nonexistent,” says Blanchard. “Telehealth could make that care available to patients for whom it would otherwise be out of reach.”