How are primary care behavioral health programs funded?
Author: Neftali Serrano
There are a variety of ways that organizations use to fund primary care behavioral health programs.
- Some organizations decide to forgo billing for services rendered either because of existing grant funding, difficulties with billing for services in their state or county or simply a philosophical decision to fold the costs of the behavioral health consultation service into the overall budget of the clinic. In governmental organizations such as the Veterans Administration medical system, primary care behavioral health programs are funded globally through the organization’s budget and do not require billing.
- Other organizations use grant funding, often from governmental agencies such as the Human Resources and Services Agency (HRSA) or locally-based grantee organizations.
- Most organizations attempt to bill for services rendered by behavioral health consultants.
Billing for PCBH Services:
Billing for primary care behavioral health services is functionally identical to billing for specialty mental health services and as such is dependent on local, state and federal regulations. Therefore, it is impossible to generalize regarding the ability of organizations to bill for services; however, references have been developed to assist program developers with obtaining information related to their particular state.
State specific billing and financial worksheets can be found here.
The most typical codes utilized by behavioral health consultants when billing are the current set of psychotherapy codes as well as the health and behavior codes. A description of psychotherapy codes can be found here.
A description of health and behavior codes can be found here (However, be aware that health and behavior codes are not recognized by every payer.)
Billing for professional services always requires a licensed and credentialed mental health provider, and the two most commonly reimbursed in primary care include psychologists and licensed clinical social workers. Other professional licenses such as licensed professional counselors and marriage and family therapists may be eligible for reimbursement within primary care in certain states and localities.
In a minority of cases, special arrangements have been made between payers and either counties or specific health service providers to establish alternative payment systems including unique billing codes for use in integrated primary care settings
Barriers to Billing for PCBH
There are certain barriers to billing for services that are unique to the primary care behavioral health model. When faced with these barriers (see this Commonwealth Fund report for a detailed description of billing issues), many organizations engage in advocacy work through their state primary care associations and through conversations with local payers educating them about the benefits of the primary care behavioral health model. These include:
- Regulations that exist in some states that prohibit billing for a mental health encounter and a primary care encounter on the same day. This is particularly challenging for sustainability since behavioral health consultants typically see 50% or more of their daily patient volume from warm handoffs or same-day visits as referred by primary care providers.
- Another important barrier are the requirements of some payers, usually commercial or managed care organizations, who require prior authorizations or permission for the patient to be seen by the mental health professional prior to a scheduled visit. This again interferes with the seamless handoff of a patient from primary care provider to behavioral health consultants.
- Copayments for services rendered are another potential barrier to seamless warm handoffs. Copayments are the portion of the bill for which a payer has determined the patient is responsible based on the nature of their insurance coverage. This can interfere with a warm handoff by dissuading a patient from engaging in the additional service due to having to pay an additional fee to see the behavioral health consultant.
- Deductibles for mental health care similarly pose a challenge for patients and behavioral health consultants. In many cases, patients are ill-informed of either of these responsibilities and may be billed subsequent to a visit. In some cases where it is possible, clinics may make the decision to forgo or write off the copayment portion of the visit in order to encourage integrated practice.
Finally, it is important to note that there are many activities in which a behavioral health consultant engages that are not reimbursed at all in the fee-for-service scheme that dominates the payer system today. For example, behavioral health consultants regularly provide curbside consultations to primary care providers even for patients that they do not physically see in the clinic; they provide telephone consultations to patients; engage in care management activities using patient registries to improve patient care; and they may manage ancillary consultation services such as referrals to consulting psychiatry services. There are no current mechanisms in place that account for these value added activities.
Although the barriers to billing effectively in certain localities are significant, the primary care behavioral health model has certain advantages over other integrated care models such as SBIRT or collaborative care models such as IMPACT in that behavioral health consultants are always licensed mental health professionals with established billing opportunities. In these other models, which may utilize bachelors-level health coaches, care managers, or nurses, the opportunities for billing have to be specially created.
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