The payment, reimbursement, and billing issues around behavioral health are substantial. Psychiatry was not considered insurable until 30 years ago, and limitations exist related to reimbursement for psychotherapy. An understanding of the size and scope of the behavioral health workforce is an important area of inquiry that will be even more useful when complemented by an understanding of the opportunities and barriers that exist related to reimbursement. In other words, can we match capacity with opportunity, or understand how reimbursement policy is inhibiting access to care?

This research will enhance our understanding of the behavioral health workforce by documenting on a state-by-state level which types of behavioral health practitioners can be reimbursed for what kinds of services within Medicaid, and what services are allowable under the state scope of practice but restricted by reimbursement policy. This project will also summarize Medicare reimbursement policy and provide several state examples of the implications of these policies. A sample of private insurance policies will also be examined.

Findings

Balancing the disequilibrium between the demand for mental health and substance use disorder services and the supply of qualified behavioral health professionals compels an examination of the billing and reimbursement practices and payer policies impacting behavioral health service access. One strategy to enhance workforce capacity is to ensure that behavioral health professionals can receive reimbursement for common procedures in behavioral health, especially when those services fall well within their expertise and scope of practice.

This study investigated the use of current procedural terminology (CPT) codes by psychiatrists, clinical psychologists, licensed clinical social workers, licensed professional counselors, and licensed marriage and family therapists for service reimbursement across three payer types: Medicare, Medicaid, and private insurance providers. Across Medicaid and Medicare, almost all relevant CPT codes could be used by providers to bill for authorized services unless the service is outside the provider’s scope of work.  In cases where codes are disallowed by provider type, other codes may be used to provide similar or more targeted services.

In the current climate of provider shortages, it is important to leverage the existing workforce and reinforce high-quality service through recognition in reimbursement. While these findings suggest that the behavioral health professionals in this study are generally recognized as approved providers, further research into the actual payment rates is recommended in order to enrich these data. Misalignment of reimbursement with value of care can act as a disincentive toward high-quality, coordinated care. With the healthcare system’s move toward integrated and coordinated value-based contracting, the barriers to reimbursement referenced in this report may be organically addressed as payers acknowledge the value of non-licensed professionals, team-based care, and other approaches that drive down healthcare costs and result in higher quality and better client experiences.

Partners

Researchers

Teresa Halladay, MA
Megan Dormond, MPH
Xavior Robinson, MHSA
Jake Bowling, MSW
Sara Afayee, MSW