Mental health services in primary care
Integrating behavior health services into the primary care setting can be beneficial for the patient as well as profitable for the pediatrician.
A main barrier, he says, is the lower reimbursement rate for submitting mental health claims using mental health codes. “Medical codes get reimbursed better than psych codes,” he says, “so if you bill medically and use medical codes you get better reimbursement.”
Rabinowitz says that his clinic initially used psych codes for reimbursement but found the reimbursement rates insufficient for covering the cost of running a medical office. His clinic switched to using standard evaluation and management (E/M) codes that, he says, work well.
In order to use E/M codes, however, he emphasizes the need to work with insurance companies and Medicaid to ensure these codes can be used to reimburse mental health services rendered. Saying that most insurance companies contract with behavior health organizations and therefore are limited in negotiating written agreements to honor E/M codes for reimbursement for mental health services, he nonetheless says that his clinic has been able to negotiate agreements by select insurance companies to use E/M codes for this reimbursement.
For Medicaid, he stresses the importance of getting written permission to use E/M codes for mental health services reimbursement.
Calling this arrangement a “financial integration” reimbursement model, Rabinowitz stresses that using this type of reimbursement option requires research to come up with a reimbursement structure that works within regional/state laws (Table 4). “Each state has its own rules as to what is allowed,” he notes.
For example, Rabinowitz and his colleagues researched and discovered a law in Colorado that allowed registered nurses working under a licensed dermatologist or plastic surgeon to be reimbursed for providing skin cosmetic services (ie, Botox). He says that his clinic physicians have applied this rule in their practice to successfully get reimbursement for mental health services provided by their in-house mental health provider.
Along with working with state laws to find ways to get reimbursed by private insurers, Rabinowitz emphasizes the importance of negotiating with a state Medicaid representative to get reimbursement of coverage for children covered by Medicaid.
As the number of children with mental health issues increases, so does the need to find better ways to get these children the help they need. One way is to provide easier access and continuity of care by integrating mental health services into the primary care setting.
To do this, pediatric practices need to think about the type of arrangement that works best for their particular practice, the type of provider to use, and protocols that will help the integration run smoothly and well.
Critical and most challenging is the need to find a reimbursement option that permits sufficient reimbursement for mental health services to make integration a viable option. Practices will need to research and work with state laws and private insurance plans to develop a reimbursement plan that works best for them.
1. US Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999. https://profiles.nlm.nih.gov/ps/access/NNBBHS.pdf. Accessed February 24, 2017.
2. American Academy of Child and Adolescent Psychiatry Committee on Health Care Access and Economics Task Force on Mental Health. Improving mental health services in primary care: reducing administrative and financial barriers to access and collaboration. Pediatrics. 2009;123(4):1248-1251. Erratum in: Pediatrics. 2009;123(6):1611.
3. National Alliance on Mental Illness. Mental health by the numbers. Available at: http://www.nami.org/Learn-More/Mental-Health-By-the-Numbers. Accessed February 24, 2017.
4. O’Connor BC, Lewandowski RE, Rodriguez S, et al. Usual care for adolescent depression from symptom identification through treatment initiation. JAMA Pediatr. 2016;170(4):373-380.
5. Soni A. The five most costly children's conditions, 2006: estimates for the US civilian noninstitutionalized children, ages 0-17. Statistical brief #242. Rockville, MD: Agency for Healthcare Research and Quality; 2009. Available at: https://meps.ahrq.gov/data_files/publications/st242/stat242.pdf. Accessed February 24, 2017.