4 Payer Data Points That Demonstrate Behavioral, Mental Care Parity

Percentage of out-of-network mental, behavioral healthcare claims

The first data point is the percentage of allowed inpatient and outpatient out-of-network claims for providers who are mental and behavioral healthcare professionals and for medical and surgical providers. If there is a difference of five percent or more for allowed out-of-network claims, then parity does not exist and health plans must take corrective action.

A study published in JAMA Open Network found that Americans were paying for out-of-network behavioral and mental healthcare services at a higher rate than they were paying for any other kind of out-of-network care. The cost was evident in high out-of-pocket healthcare spending for substance abuse care and similar services. When compared to diabetes—frequently listed as one of the most expensive chronic diseases—the study found that patients receiving mental healthcare support were paying $341 more per year in cost-sharing than patients with diabetes.

Mental, behavioral in-network reimbursement rates versus clinical care

The second item that employers should ask for is in-network reimbursement rates, Harbin and the Path Forward Initiative suggested. This should be compared to the medical and surgical reimbursement rates and measured against Medicare for benchmark comparisons.

If primary care providers and non-psychiatrist medical and surgical specialists receive more than 100 percent of the reimbursement rate that behavioral and mental healthcare specialists receive, then the health plan must take corrective action.

Some payers have been trying to better incorporate mental and behavioral healthcare reimbursement through value-based reimbursement models. Value-based reimbursement strategies help payers align incentives with their behavioral and mental healthcare partners.

Blue Cross Blue Shield North Carolina established a value-based reimbursement model with its partner Quartet in which the behavioral and mental healthcare provider network took on upside risk. BlueCross BlueShield of Western New York likewise implemented an upside risk value-based reimbursement model with its behavioral healthcare provider, a critical step in a region plagued by the opioids epidemic.

“BlueCross BlueShield of Western New York is proud to partner with the region’s leading behavioral health care providers to introduce the first payment model designed to directly enhance quality care for our members with mental health and/or substance use disorder diagnoses,” said Thomas Schenk, MD, senior vice president and chief medical officer at BlueCross BlueShield of Western New York.

Mental, behavioral healthcare services denial rate

The third data point is the denial rate. Health plans would need to report to employers how often they refuse coverage for a behavioral or mental healthcare request. This includes inpatient, outpatient, and in-office visits as well as denials for which no claim was submitted and claims that were denied authorization.

“If you're denying mental health care—inpatient or outpatient—more frequently than medical, that's a sign that you're maybe blocking access,” Harbin pointed out.

The National Association on Mental Illness (NAMI) has a webpage dedicated to informing patients of actions they can take when denied coverage for mental healthcare services. The page walks patients through how to know whether they have a right to appeal their coverage denial. It also provides several steps to take if a health plan continues to resist.

NAMI released a report in 2015—one of the few reports readily available that highlight this issue—which surveyed 2,720 individuals with mental healthcare needs or connected to a family member with mental healthcare needs.

Almost 30 percent of the participants responded that they or a family member had been denied mental healthcare on the grounds that it was not found medically necessary (29 percent). Another 18 percent reported being denied substance abuse care for the same reason. In comparison, 14 percent said that they had been denied medical care due to lack of medical necessity.

Network directory accuracy

The final data point that employers may start asking for is network directory accuracy.

This data point reveals whether or not the type of provider in the network is the kind of provider that patients and employees need. If a provider is listed as in-network but rarely sees patients from that employer or health plan, then the employer would have reason to believe that the health plan may not be offering the type of care that her employees need. Less than ten percent of pyschiatrists on the provider network should be seeing zero claims or less than five unique patients in the six months prior to the data request.

“That would be a sign that you don't really have a valid network, if 20, 30, 40 percent of the providers are not seeing any patients,” Harbin explained.

It is no longer just employers asking for this. Harbin said that state regulators have joined in the call for health plans to start studying their own parity on a more regular basis.

Telemental and telebehavioral healthcare parity certainly got a major boost from coronavirus-related widespread utilization which forced greater reimbursement equality.

But the call for overall mental and behavioral healthcare parity has resounded since long before the coronavirus pandemic. The question remains whether payers, providers, and employers will come to an agreement on how to achieve parity across all mental and behavioral healthcare services.

Harbin was optimistic about the future of parity, given payers’ recent actions.

“A number of health plans are making efforts to equalize payment or pay better. They're pushing hard for the plans to accelerate things like faster credentialing in-network care,” Harbin said. “So I would say, it's certainly not going to pace we would like, but I see a lot of efforts that can make a big difference from a lot of players that weren't that active before.”

Nevertheless, the current state of mental and behavioral healthcare parity is unclear and, Harbin warned, it could remain unclear for a couple of years as researchers gather data.

“I'm hopeful I think, on the parity front,” Harbin said. “We did see a lot of health plans say they wanted to address these deficits and in network access and tips taking steps.”

But, he emphasized, it is still too early to tell what the real impacts of coronavirus on behavioral and mental healthcare parity will be.