Payers often have behavioral health carve-outs in coverage policies to contract with providers that will specifically provide mental healthcare to members, but this practice is preventing access to care, according to Kaiser Health News.
An example of this issue is a Cincinnati physician submitting a claim to a patient's insurance using one code for obesity, one for rosacea, one for anxiety and one for attention-deficit/hyperactivity disorder.
The patient was in network for physical care. Weeks later, the payer denied coverage for the patient's visit, saying "the services billed are for the treatment of a behavioral health condition," and those benefits come from a separate provider. Despite the patient being in network with the physician, they would still have to cover the cost of the behavioral services.
This type of policy carve-out is aimed at lowering costs and allowing providers with a mental health focus to manage the benefits, according to KHN.
The strategy, however, forces patients to navigate two different provider networks, which in turn often deny claims and cite the other's responsibility for it — leaving the patient in the middle.
Despite physicians reporting the problem, there is little data to show how often the issue is occurring. Sterling Ransone Jr., MD, president of the American Academy of Family Physicians, told KHN he has been receiving "more and more reports" about it since the emergence of COVID-19.
Peter Liepmann, MD, a physician in California, told KHN that he had stopped using psychiatric diagnosis codes in claims at one point. To get paid, he would code depression as fatigue or anxiety as palpitations.
Physicians can appeal claim denials or attempt to collect payment from the carve-out plan, but it often isn't worth the time spent.
Kate Berry, senior vice president of clinical affairs at AHIP, told KHN many payers are working to help members get mental healthcare through their physician by teaching providers standardized screening tools and proper billing codes, but many aren't able to do it.
A potential solution is simply ditching the carve-outs for behavioral and mental health services, though that could result in more narrow networks for members, according to KHN.