The Affordable Care Act required health insurance plans to include behavioral health coverage, and that has benefits for patients, physicians and payers alike.
March 23, 2019, marked the ninth anniversary of The Patient Protection and Affordable Care Act (ACA) being signed into law. These past nine years have been a continuing debate regarding the various aspects of health insurance reform contained in the ACA.
The most fundamental of reforms arose out of the simple definition of “essential health benefits.” For the first time in our nation’s history, health insurance plans were obligated to include “mental health and substance use disorder services, including behavioral health treatment” as covered benefits in their policies.
Behavioral health (BH) providers, who previously had very little exposure prior to the ACA, have been on a sharp learning curve when it comes to dealing with commercial payers.
However, much to the surprise of the BH community, payers are running toward alternative payment models that have been commonly utilized in BH for decades. Capitation and risk arrangements are a way of life for BH providers. Capitalizing on this knowledge is critical for any primary care physician (PCP) looking to integrate BH into his/her practice.
Beyond gaining a working knowledge of managing a patient under alternative payment models, what makes the case for integration? Simply put, BH conditions generally go undiagnosed and untreated.
The following list of statistics published by the Patient-Centered Primary Care Collaborative demonstrate precisely why outcomes can be so dramatically improved among patient populations when BH is integrated into primary care. They further demonstrate why integration of BH is the secret to bending the cost curve:
If the above statistics are not enough to convince your practice that the real opportunity for population health improvement lies with BH integration, consider these financial benefits, also published by the Patient-Centered Primary Care Collaborative:
So, what can a practice do to integrate BH? Here are three practical steps to consider:
In January 2018, CPT added codes for BH integration. CPT 99484 can be used with at least 20 minutes of clinical staff time, directed by a physician or other qualified healthcare professional (e.g., physician assistant; nurse practitioner; or specialist such as cardiologist or oncologist), per calendar month with the following required elements:
BH integrated services that are not provided personally by the billing practitioner are provided by other members of the care team under the direction of the billing practitioner on an “incident to” basis as an integral part of services provided by the billing practitioner.
Beyond the general BH integration code, three additional codes are available with a psychiatric consultant. These codes are for the PCP. The psychiatric consultant bills separately for his/her services.
CPT 99492 is used for initial care management (the first 70 minutes in the first month of behavioral healthcare management activities) in consultation with a psychiatric consultant and directed by the treating physician or other qualified healthcare professional.
CPT 99493 is used for subsequent collaborative care management, and CPT 99494 is used for each additional 30 minutes in a calendar month for initial or subsequent collaborative care management. Thus, CPT 99494 would be listed separately but in conjunction with CPT codes 99492/3.
A BH integration fact sheet issued by CMS that lays out these psychiatric collaborative care codes does not dictate the appropriate business model. Several business models exist with varying degrees of success. Traditional referral relationships are not as effective as co-location, direct staffing or participation in a BH provider driven clinically integrated network (CIN).
There are CINs of all shapes and sizes emerging in the market as providers begin to collaborate over care management, best practices and outcome measures. The most successful are those led by BH providers who are driving collaborative care centered around BH integration into a primary care.
In essence, these BH focused CINs take a Patient-Centered Medical Home (PCMH) and/or a Certified Community Behavioral Health Clinic (CCBHC) to the next level by structuring collaboration/integration in a way that keeps patients engaged and creates metric measurements that attract payers to alternative contracting models.
Russell A. Kolsrud, JD, is a Member at Dickinson Wright PLLC and focuses his practice on the healthcare industry. For the past 10 years, Russ’ primary focus is the jurisprudence of behavioral health and its integration with acute care. He also advises on implementation of strategies to achieve integration and bend the healthcare cost curve give rise to unique, revolutionary and consequential legal challenges for providers, payers, states and federal programs.
Gregory W. Moore, JD, is a Member at Dickinson Wright PLLC and has been a practicing healthcare attorney since 1991. During his career, he has focused on representing and counseling providers of all types and sizes across all existing and developing segments of the healthcare industry. Like Russell, Gregory has spent the last 10 years focusing primarily the integration of behavioral health and physical health.
Russell and Gregory together created a Behavioral Health Care Law Practice Group, the first of its kind in a national law firm. With more than 50 years of combined experience, Russell and Gregory guide their clients through the highly nuanced Patient Protection and Affordable Care Act, the Parity Act, the design of a health information exchange with a platform premised on compliance with secondary disclosure restrictions of 42 C.F.R. Part 2, and the business and legal stress associated with these challenges.