While many providers recognize there are benefits to integrating behavioral health and primary care, reimbursement for services continue to be one of the most challenging barriers to achieving integration. The Mental Health Parity and Addiction Equity Act of 2008 and the 21st Century Cures Act signed into law in December 2016 are efforts made by Congress to reduce the lack of coverage for behavioral health services and improve the coordination of behavioral health and primary care. These laws are requiring providers, health plans and insurers to offer equal access and scopes of services to behavioral health patients as those provided to patients receiving physical medical services. This represents a big step forward in minimizing the reimbursement barrier because government and commercial payers are being required to develop payment methodologies that will reimburse health services provided in an integrated setting.

In addition, health care entities should develop integrated care models that will maximize financial sustainability by carefully considering the license of the facility where the integrated services will be provided, the scope of practice of each licensed professional, the billing codes that can be used for mental and behavioral health services and reimbursement requirements under their payer contracts.

Below are tips and matters to consider when developing a financially sustainable behavioral health and primary care integrated care model.

Facility License: Integrated care models can be provided in a variety of settings; however, where services are provided can definitely have an impact on reimbursement. Community Mental Health Centers (“CMHCs”) are licensed by a state agency governing mental health services and are required to provide comprehensive mental health services to the public. CMHCs usually receive funding through Medicaid contracts and grants. Federally qualified health centers are outpatient clinics that qualify for the prospective payment system reimbursement rate under Medicare and Medicaid and must meet certain eligibility requirements. Substance use disorder treatment facilities, hospital-based outpatient programs and other health care facilities may require a separate license to provide services in an integrated setting. When evaluating which integrated treatment setting will provide financial sustainability, health care entities must review current licensure regulations and the payment structures for the licensed facilities to maximize reimbursement.

Licensed Professionals: In order for mental and behavioral health services to be paid, government and commercial payers generally require licensed professionals to work within their state-defined scope of practice and be credentialed by the payer. Since states vary in the scope of practice for certain mental and behavioral health providers, some providers’ services are not reimbursable by certain payers. For example, Medicare covers reasonable and necessary services furnished by psychologists and clinical social workers but does not cover services provided by licensed professional counselors. Under certain circumstances, services furnished by non-credentialed providers may be reimbursable if performed under the direct supervision of a credentialed provider. Health care entities must evaluate the scope of practice for the licensed professionals that will be a part of the integrated model and align the furnishing of services by credentialed and non-credentialed providers with the reimbursement requirements of the payers. Understanding the scope of practice for each licensed professional and payer reimbursement requirements will also allow health care entities to develop a workflow that will help maximize financial sustainability.

Billing Codes: Knowing and understanding the billing codes for mental and behavioral health services is critical to financial sustainability. Medicare and Medicaid billing codes for mental health services will fall within the Evaluation and Management (selected codes within range 99201–99340) and the Medicine sections of the CPT codes. Within the Medicine section, the two areas that apply specifically to mental health services are the Psychiatry codes (90801–90899) and the Health Behavioral Assessment and Intervention codes (96150–96155).

Billing codes across commercial payers vary. Some commercial payers reimburse for alcohol and drug screening, brief intervention and referral-to-treatment services when provided and billed by a credentialed provider. Some may reimburse services, in certain scenarios, when providers use appropriate evaluation and management codes based on standard components or time criteria and depending on the contract with the commercial payer. Some commercial payers will implement special programs to address issues like depression and have certain billing codes for the program. Regardless of the payer, health care entities should know all codes that will allow for reimbursement of mental and behavioral health services in an integrated setting.

Payer Contracts: Review all payer contracts and health plans to determine which licensed professionals can be credentialed for reimbursement and what billing codes exist for reimbursement of mental and behavioral services in an integrated setting. To the extent there are licensed professionals and/or services that are not being reimbursed by the payers, develop a plan to approach the payers to make the business case for reimbursement.

For example, if you have licensed professional counselors that cannot be credentialed by a payer, you could provide data to the payer demonstrating that licensed professional counselors are far more accessible than psychologist and clinical social workers; thus, to avoid issues of access, the payer should credential licensed professional counselors. In making the business case, use claims data to demonstrate how credentialing the licensed professional counselors will allow your entity to provide mental and behavioral health services in an integrated setting that will help improve health outcomes and reduce the payers’ cost in other settings such as emergency care, hospital admissions or long-term care.

Practical Takeaways

  • Review facility licensure requirements to determine if the licensure and reimbursement structure is the best for your integrated care model.
  • Review state scope of practice requirements for your licensed professionals and verify if the individuals can be credentialed under current government and commercial payer contracts.
  • Know the mental and behavioral health codes available for government and commercial payers.
  • Review payer contracts to make certain the professionals working in the integrated setting can be credentialed and understand and know the billing requirements under the contract.
  • Review claims data from payers to determine the best approach for negotiating the credentialing of certain professionals and requesting the addition of mental and behavioral health billing codes.