Teaching mental health providers how to navigate the managed care industry and increase cash flow

Mental Health Parity and What It Means for You

Posted by on Nov 12, 2013 in Mental Health, Psychotherapy | 0 comments

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ID-100173816Recently, the federal government announced new rules regarding how mental health benefits should be treated by insurance companies. (Full Disclosure: I currently work in managed care.) In a nutshell, the regulations confirm that mental health benefits can be no more restrictive than their medical coverage, also known as parity.

The move towards parity has been in the works since the passage of the Mental Health Parity and Addiction Act in 2008.  The new rules ensure that benefits and guidelines that govern medical coverage are similar to those that govern mental health. So if a visit to a doctor has a co-pay of $30, then a similar co-pay should apply to a visit to the psychotherapist. The new rules also address the treatment of addictions, and the ability to receive care out of state if necessary. The rules also ensures patients and providers are made aware of what are covered in the benefits and if coverage is denied, how to appeal the decision.

Now here’s what it doesn’t mean. It doesn’t mean that mental health benefits are unmanaged as in a patient can be seen on an ongoing basis because he has a diagnosis.  It doesn’t mean that every diagnosis is covered. It doesn’t mean that every form of treatment is covered. It does mean that managed care companies are basing reimbursement on using the same guidelines that are used on the medical side. Those guidelines include having measurable treatment goals and using interventions that are focused on the problem and intended to restore baseline functioning. The guidelines also stipulate that as the patient improves, a plan for tapering and eventual discharge also be established. The guidelines usually don’t support treatment for the purposes of supportive therapy.

With that being said, here are a few tips if you are using your benefits or accept insurance for mental health or substance abuse treatment

1. Prior to seeking treatment, call and verify your benefits and what is covered under the benefit. Check to see if you will need a prior authorization or notification to receive care.

2. If you are a mental health provider, always, always, always verify the patients benefits. Verify if the benefit excludes coverage for certain diagnoses (i.e. personality disorder as a primary diagnosis) or billing codes.

3. Many managed care companies have their guidelines published on their websites. If you have trouble finding them, call and ask for them. It’s always better to know what the guidelines are and how to apply them.

4. Again, if you disagree with the decision made by your insurance company, you have the right to appeal. But don’t wait too long, you have a certain amount of time to appeal the decision.

5. I’m going to say it again. Never, ever, ever, and I mean never assume anything when it comes to benefits. Verify everything.


Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net 

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