Earlier this year, the Centers for Medicare & Medicaid Services (CMS) took a major step toward improving access to behavioral health care with the launch of the Innovation in Behavioral Health Model. The model advances the framework for integrated behavioral health (IBH)—a holistic approach to care that emphasizes collaboration between primary care and behavioral health providers. One of the model’s main objectives is to reduce fragmentation and implement new provider payment and incentives for IBH. Despite the model’s promise, however, commercial payers have been slower to develop solutions to support providers in IBH.
How IBH Works
IBH is not a new concept, and integrating physical and behavioral healthcare has long been widely accepted from a clinical perspective as the gold standard of treatment. The Innovation in Behavioral Health model aims to propel IBH forward by offering solutions to many of the most difficult operational challenges: health technology infrastructure, payments for care management, and performance-based payments. Under this new model, the behavioral health setting is the point of entry, with behavioral health clinicians acting as the leader of the team by initiating assessments, coordinating the care team, and participating in care planning.
Earlier efforts to integrate physical and behavioral healthcare targeted integration in the primary care setting via the Collaborative Care Model (CoCM). This model of IBH utilizes care managers and psychiatric consultants in a supporting role to facilitate behavioral health treatment by the primary care provider. CoCM provides an avenue for identifying and treating low-acuity behavioral health needs within the primary care setting, preserving traditional behavioral health services for patients with more severe behavioral health needs.
While CoCM increases access to behavioral health treatment and promises both clinical benefits and cost savings, administration—including billing and payment—is burdensome. Primary care providers are responsible for staffing the care team, billing insurance companies, and then administering payment downstream to the behavioral health care team. These tasks are unpaid and require significant time and resource investment from the care providers.
Commercial Payers Lack IBH Infrastructure
CMS anticipates that its new approach will reduce common barriers and inefficiencies within IBH and improve care for the estimated 25% of Medicare beneficiaries experiencing mental illness and the 40% of adult Medicaid beneficiaries experiencing mental illness or substance use disorder (SUD). Commercial payers, however, despite seeing a continuous growth in demand for behavioral health services, continue to lack the financial and operational infrastructure to support providers in their development of IBH programs.
With most large commercial payers still operating behavioral health network operations separately from their physical health network, providers interested in offering IBH programs are left to navigate the complexity of financially connected but operationally disconnected entities. Even under a single payer, establishing reimbursement for IBH may require obtaining separate provider agreements from different organizations, which involves administrative hurdles starting with initial contracting and persisting throughout the revenue cycle process.
For many large commercial payers, steps to obtain an agreement and get paid for IBH services include the following:
- Contracting: Behavioral and physical health provider agreements may be administered by separate entities, each with their own contracting representatives, network applications, requirements for supporting documents, and processing time frames. Distinct provider records may need to be created in each provider data management system to hold provider demographic data, contract information, and claims history.
- Managing payer requirements: Each provider agreement may have its own terms and conditions, supplemented by a provider manual, outlining important requirements for provider participation in the network. Requirements involving dispute resolution, contract termination, and timely filing of claims, among others, may vary between physical and behavioral health entities.
- Claims submission and payment: Claims with both physical and behavioral health services may require dual processing by separate claims systems. Two payments are issued for a single member with one health insurance plan, adding complexity to tracking payments as well as identifying and resolving incorrectly paid claims. Lack of interoperability between provider data management systems typically precludes payer representatives on the physical and behavioral health sides from collaborating to resolve payment issues, leaving providers to spend many unpaid hours each week resolving payment issues between multiple provider representatives.
Making IBH a Reality
Even large provider organizations with dedicated managed care teams struggle to manage requirements, claims, and payments across multiple fragmented organizations that are considered part of a single payer. But with over 150 million people living in designated mental health professional shortage areas, the onus of care cannot fall solely on mental health providers. The concept of bringing behavioral health providers and PCPs under one common payer program will continue to gain momentum as a means to improve health outcomes and control healthcare spending.
Commercial payers will need to develop avenues to reduce the deep administrative burden on providers who want to pioneer IBH programs for their patients. This will require payers’ physical and behavioral health business segments—historically operating in silos—to work collaboratively. Further, commercial payers will need to mirror CMS’s efforts to fairly compensate and incentivize providers for engaging in IBH.
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