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

HIPAA, Mental Health, and Managed Care

Posted by on Dec 3, 2013 in HIPAA, Managed Care, Mental Health, Psychotherapy | 0 comments

13 Flares Twitter 0 Facebook 11 Google+ 2 StumbleUpon 0 Pin It Share 0 LinkedIn 0 Email -- Buffer 0 Filament.io 13 Flares ×

ID-100213905There is a labyrinth of regulations called HIPAA that mental health and medical professionals have to navigate in order to remain in business. The Health Insurance Portability and Accountability Act of 1996 was established to create standards related to the creation and maintenance of electronic health records. It was also meant to regulate how Protected Health Information is used. Here’s why this is important. If a patient is being seen for a medical or mental health issues, they need to feel confident in the knowledge that their information won’t be sent to their employer. Or what if the patient is going through a divorce and/or child custody hearings? How likely are patients to be honest with their doctor or counselor if there is constant fear that their PHI will become public knowledge.

In my experience, medical and mental health professionals are very diligent about protecting the confidentiality of the client. However, there is an exclusion in HIPAA that many mental health professionals and the general population is not fully aware. It’s called the Treatment Payment Operations (TPO) HIPAA Exclusion. The exclusion states that if a patient is using insurance, then he is allowing the insurance company to obtain information from provider and coordinate care. The key words being “if the patient is using the insurance.” This applies whether the mental health provider participates in the plan or not. If you are a mental health provider and you participate or are “in-network” with that patient’s plan, typically you have a contractual obligation to coordinate care with the insurance company. Out of network providers do not have the same obligation. However, managed care companies can refuse to pay due to a lack of information. Think of it in terms of getting a loan from a bank. If a long standing customer walks into a bank and asks for a loan, the bank will want certain information from the customer to see if they qualify. The customer can say “You don’t need that information. I’ve been a customer for years. Just give me the loan.” But the bank reserves the right to not grant the loan based on a lack of information. Or based on the information given, doesn’t meet guidelines for being granted a loan. Using insurance benefits works in much the same way. In order to receive reimbursement, the care has to meet the guidelines. In order to see if the care is meeting the guidelines, insurance companies may ask for additional information regarding the patient’s care including a treatment plan and a plan for discharge.

In my time working in managed care, I have heard objections that it’s a violation of HIPAA to request such information. Well, from the TPO exclusion, it is not. The key is that managed care companies require the minimal necessary information to make a decision based on HIPAA. Typically, this includes the diagnosis, the treatment plan, the progress, and discharge plan. Some companies require this information in writing while other require a telephonic review. But the overall goal of the review is to determine if the care is meeting the guidelines, not to deny benefits.

So if you are a mental health provider and you are in a situation that requires you to give a clinical review to the managed care company, remember that it does not violate HIPAA to do so. I would recommend that if your patient is using insurance, you inform them at the beginning of treatment that their insurance may ask additional questions regarding their treatment and that using insurance gives the insurance company the right to request the information. It is also advisable that you have a proper release of information on file as well. This protects both you and the client. Also remember that insurance companies are not required to share information with employers due to HIPAA as well.

If you’re a mental health provider and you have had trouble getting along with managed care companies, let me help you. Many mental health providers just don’t have the time to learn the rules of how insurance works and become frustrated due to not getting paid in a timely manner. I can help you navigate the managed care industry and increase your cash flow. For more info, contact me at 321-800-8520   Image courtesy of Stuart Miles at FreeDigitalPhotos.net

Leave a Comment

Your email address will not be published. Required fields are marked *

13 Flares Twitter 0 Facebook 11 Google+ 2 StumbleUpon 0 Pin It Share 0 LinkedIn 0 Email -- Buffer 0 Filament.io 13 Flares ×