Now, with the added mental stress of a two-year pandemic, “we’re seeing more visits to our offices with issues of anxiety, depression, etc.,” Ransone said.
This means doctors are submitting more claims with mental health codes, which creates more opportunities for denial. Doctors can appeal such denials or try to collect payment from the carve-out plan. But in a recent email discussion among family physicians, which was later shared with KHN, those who run their own practices with little administrative support said the time spent on paperwork and phone calls to appeal refusal was more expensive than the final reimbursement.
Dr. Peter Liepmann, a family physician in California, told KHN that at some point he stopped using psychiatric diagnosis codes in claims altogether. If he saw a patient with depression, he coded it as fatigue. Anxiety was coded as palpitations. It was the only way to get paid, he said.
In Ohio, Sawyer and his team decided to use insurer Anthem rather than pass the bill on to the patient. In calls and emails, they asked Anthem why the request for treatment for obesity, rosacea, anxiety and ADHD had been denied. 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 to wonder if it will happen again. If so, he’s not sure the $87 refund is worth it.
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“Everyone across the country is talking about integrating physical and mental health,” Sawyer said. “But if we’re not paid to do it, we can’t do it.”
Anthem spokesman Eric Lail said in a statement to KHN that the company routinely works with clinicians who provide mental and physical health care to submit accurate codes and obtain appropriate reimbursement. Suppliers with concerns can follow the standard appeal process, he wrote.
Kate Berrysenior 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 practices – for example, coaching physicians on how to use standardized screening tools and explaining appropriate billing codes to use for integrated care.
“But not all primary care providers are ready to take on that,” she said.
A report 2021 of the Bipartisan Policy Center, a think tank in Washington, D.C., found that some primary care physicians combine mental and physical health care in their practices, but that “many lack the training, financial resources, guidance, and 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, put it this way: “A lot of primary care physicians don’t like to treat depression.” They may feel like it’s beyond their area of expertise or takes too much time.
A study focused on older patients found that some primary care physicians change the subject when patients bring up anxiety or depression, and a typical discussion about mental health lasts just two minutes.
Doctors point to lack of payment as the problem, Frank said, but they “exaggerate how often it happens.” Over the past decade, billing codes have been created to allow primary care physicians to bill for integrated physical and mental health services, he said.
Yet the split persists.
One solution might be for insurance companies or employers to end behavioral health exclusions and provide all benefits through one company. But policy experts say the change could lead to tight networks, which could force patients to go out of the network for care and pay out of pocket anyway.
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 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 the right care.
The patients, again, are the losers.
“Most of them don’t want to be sent to specialists,” Trivedi said. So when they can’t get mental health care from their GP, they often don’t get it at all. Some people are waiting until they have reached a crisis point and end up in the emergency room – a growing concern for especially children and adolescents.
“Everything is delayed,” Trivedi said. “That’s why there are more crises, more suicides. There is a price to pay for not being diagnosed or receiving adequate treatment early.
Kaiser Health News is a national health policy information service. It is an independent editorial program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.