Now with the added mental stress of a two-year pandemic, “we are seeing more visits to our offices with concerns of anxiety, depression, and more,” Ransone said.
That means doctors are submitting more claims with mental health codes, which creates more opportunities for denials. Physicians can appeal these 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 running their own practices with little administrative support said the time spent on paperwork and phone calls to appeal denials cost more than the ultimate reimbursement.
Dr. Peter Liepmann, a family physician in California, told KHN that at one 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. That was the only way to get paid, he said.
In Ohio, Sawyer and his staff decided to appeal to the insurer, Anthem, rather than pass the bill on to the patient. In calls and emails, they asked Anthem why the claim for treating obesity, rosacea, anxiety, and ADHD was denied. About two weeks later, Anthem agreed to reimburse Sawyer for the visit. The company didn’t provide an explanation for the change, Sawyer said, leaving him to wonder whether it’ll happen again. If it does, he’s not sure the $87 reimbursement is worth the hassle.
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“Everyone around 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 spokesperson Eric Lail said in a statement to KHN that the company regularly works with clinicians who provide mental and physical healthcare on submitting accurate codes and getting appropriately reimbursed. Providers with concerns can follow the standard appeals process, he wrote.
Kate Berry, senior vice president of clinical affairs at AHIP, a trade group for insurers, said many insurers are working on ways to support patients receiving mental healthcare in primary care offices — for example, coaching physicians on how to use standardized screening tools and explaining the proper billing codes to use for integrated care.
“But not every primary care provider is ready to take this on,” she said.
A 2021 report from the Bipartisan Policy Center, a think tank in Washington, D.C., found that some primary care doctors do combine mental and physical healthcare in their practices but that “many lack the training, financial resources, guidance, and staff” to do so.
Richard Frank, a co-chair of the task force that issued the report and director of the University of Southern California-Brookings Schaeffer Initiative on Health Policy, put it this way: “Lots of primary care doctors don’t like treating depression.” They may feel it’s outside the scope of their expertise or takes too much time.
One study focused on older patients found that some primary care doctors change the subject when patients bring up anxiety or depression and that a typical mental health discussion lasts just two minutes.
Doctors point to a lack of payment as the problem, Frank said, but they’re “exaggerating how often this happens.” During the past decade, billing codes have been created to allow primary care doctors to charge 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 carve-outs and provide all benefits through one company. But policy experts say the change could result in narrow networks, which might force patients to go out of network for care and pay out-of-pocket anyway.
Dr. Madhukar Trivedi, a psychiatry professor at the University of Texas Southwestern Medical Center who often trains primary care doctors to treat depression, said integrated care boils down to “a chicken-and-egg problem.” Doctors say they’ll provide mental healthcare if insurers pay for it, and insurers say they’ll pay for it if doctors provide appropriate care.
Patients, again, lose out.
“Most of them don’t want to be shipped off to specialists,” Trivedi said. So when they can’t get mental healthcare from their primary doctor, they often don’t get it at all. Some people wait until they hit a crisis point and end up in the emergency room — a rising concern for children and teens especially.
“Everything gets delayed,” Trivedi said. “That’s why there are more crises, more suicides. There’s a price to not getting diagnosed or getting adequate treatment early.”
Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.