eNewsletter - April 2016
Behavioral Health Partners
Behavioral Health Integration: Increasing Access, Improving Care and Enhancing Outcomes
By Marc Browning, RN, PsyD
Behavioral Health Integration (BHI) is a comprehensive approach to health that sees little distinction between mind and body, and focuses on overall health. The Agency for Healthcare Research and Quality defines Integrated Behavioral Healthcare as “care a patient experiences as a result of a team of primary care and behavioral health clinicians working together, using systematic and cost effective approaches to provide patient-centered care for a defined population.”
The trend towards BHI is growing because of its effectiveness in improving patient access to behavioral healthcare, enhancing both behavioral health and overall health outcomes, improving patient engagement and physician satisfaction, and reducing overall healthcare costs.
The goals of an integrated healthcare environment include: early detection, recognition and prevention of major health concerns; reduction in the cost for patients with co-morbid conditions, minimization of unnecessary medical visits and phone calls; providing timely and appropriate mental health care, and improving the overall patient experience of care.
Research indicates that the integration of primary and behavioral healthcare makes practical sense. For instance, it is noted that a third of primary care patients meet criteria for a behavioral health disorder and one-third have psychosocial concerns that impair their functioning. Furthermore, 67 percent of psychoactive substances are said to be prescribed by primary care physicians and 70 percent of primary care appointments stem from psychosocial issues.
The primary care office appears to be a major gateway for those with behavioral health needs. Additionally, most clients seek assistance for behavioral health concerns from their primary care physicians, as evidenced by the belief that 50 percent of all care for common psychiatric disorders, such as depression and anxiety, happen in the primary care setting.
The Association for Behavioral Health and Wellness indicated that more than 20 percent of patients seen in primary care display a co-morbid substance use disorder and 30 percent of primary care patients meet diagnostic criteria for depression. Moreover, 85 percent of patients with a mental health and/or substance use disorder visit a primary care physician (PCP) at least once in a 12-month period and, strikingly, 45 percent of people who complete suicide were reported to have had contact with a PCP within one month of their death.
Despite substantial contact with primary care, behavioral health needs within the population can still go unmet. Thus, behavioral health clinicians who are co-located in a PCP’s office are positioned to add extraordinary value to the traditional primary care office setting. BHI enhances the overall identification and treatment of behavioral health concerns and the primary care patient’s access to behavioral health services and treatment.
Through integration, behavioral health clinicians partner with physician/mid-level practitioners to address behavioral health needs identified in the primary care setting; develop joint plans on the behavioral health aspects of patient care, and provide crisis intervention, brief assessment, individual therapy, behavioral interventions and education for primary care patients with mental health and/or substance abuse issues and/or issues with medical compliance.
The integration of primary and behavioral health care has led to substantial improvements in depression remission rates, enhancement of self-management skills for patients with chronic conditions, better clinical outcomes than those attained through treatment in the primary care or behavioral care sectors exclusively, improved customer and provider satisfaction, and higher rates of patient adherence and retention in treatment.
The response to BHI by PCP’s has been overwhelmingly positive. The response is related to factors such as enhanced communication, comprehensive services, improvements in the management of depression, anxiety and alcohol/substance abuse, convenience of services for patients, diminished stigma, better health education, increased coordination of mental and physical healthcare treatment, and improved access to mental health services.
In the last few years, Linden Oaks Behavioral Health has started working with many PCP office’s on behavioral health integration initiatives. Through partnerships with Edward Medical Group and Elmhurst Medical Associates, Linden Oaks has started to co-locate behavioral health clinicians in these offices and the results have been encouraging as we have seen the demand for integrated services increase.
Currently, Linden Oaks is hiring additional licensed clinical psychologists and licensed clinical social workers for this new integrated setting. For more information please contact Marc Browning, RN, PsyD, Linden Oaks Behavioral Health Integration Program, at (630) 646-8013.
- Healthcare Integration in the Era of the Affordable Care Act: www.abhw.org/publications/pdf/IntegrationPaper.pdf
- Integrating Mental Health, Primary Care is Focus of IHI Webcast: http://www.aafp.org/news/practice-professional-issues/20141210mentalprimary.html
- Integrating Primary Care and Behavioral Health Services: A Compass and a Horizon: www.apa.org/practice/programs/rural/integrating-primary-behavioral.pdf
- What is Integrated Behavioral Healthcare?: www.integrationacademy.ahrq.gov/atlas/what%20Is%20Integrated%20Behavioral%20Health%20Care
Marc Browning, RN, PsyD
Dr. Browning is a registered nurse and licensed clinical psychologist with over 25 years experience in physical and behavioral healthcare. He is a graduate of the Argosy University, Illinois School of Professional Psychology. Dr. Browning is the Director of the Linden Oaks Medical Group Counseling Services and provides oversight to the Linden Oaks Behavioral Health Integration Program.
Tips for utilization reviews
By Kelly Grill-Cooper, MS, LCPC
I am willing to bet that, like me, many of you in the behavioral health services field would agree that it can be challenging to juggle the limitations of our patients insurance coverage and the responsibility we have to provide the most appropriate treatment possible.
Many times, I would leave a utilization treatment review with an insurance company questioning if I utilized my behavioral health training and years of experience effectively to accurately defend the best clinical considerations of the case.
As I spoke to other clinicians, it became apparent that many of us shared this notion, which got me wondering: how can I do better to achieve better results?
Ultimately, by pursing advanced education on the insurance world and policy, I was able to navigate managed care and more effectively serve my patients. Full disclosure: I am not a lawyer; however, below is what I have learned along the way and some general tips to keep in mind when you have a treatment review with an insurance company:
- Benefits Shemenefits.
It is imperative to recognize that just because a patient has a behavioral health benefit, does not mean that you will be permitted to use it. When a benefit is denied, this is where the clinical sell, typically executed through Utilization Review department or team, comes into play. These departments are comprised of skilled staff who may also be licensed social workers, therapists/counselors and nurses. These individuals report clinical information (frequently referred to as clinicals) to the insurance company as it is documented in the patient's chart. It helps if the individuals communicating this information have a good command of clinical criteria (standards set forth by the insurance company) that the insurance representative is using to support their clinical perspective. For example, when supporting a chemical dependency case in the state of Illinois for a patient with a fully-insured/exchange plan, it is important to support the medical necessity of the case by use of the American Society of Addiction Medicine (ASAM) treatment criteria.
- Its only works if you work it.
Parity Law is a law that requires certain health plans to apply similar rules to mental health and substance use benefits as they do to physical health benefits. Well….what does that mean when there is rarely an “apples to apples” comparison on the medical side? It means that you need to be ready to defend your clinical stance and use of a benefit by educating yourself on Parity Law at both at the Federal and State level.
- Caring is sharing.
Fiduciary liability. Great word. What does it mean? As stakeholders in their members overall healthcare, insurance companies are now required to care about the insured individual’s whole course of care regardless of the financial implications. In the federal appellate court, a verdict was handed down that an insurance company has an obligation to act as a fiduciary, that is, as a party that has a legal/ethical responsibility to their members and places the interest of their members sometimes ahead of their own. Health plans that violate mental health parity laws, even as third party administrators, can be found liable in many cases. What does this mean for you? Health plans are required to comply with mental health parity laws and could give rise to liability if they don’t.
- Follow the yellow brick road.
Following the medical necessity guidelines set forth by the insurance company ensures that the dialogue follows a specific path and a check list and takes the “subjectivity” out of the clinical merits of the case. Having said that, I have had cases that I felt were virtual slam dunks and ended up being denied even though I felt had appropriate criteria. This is where you could exercise your authority over Parity law and ask for copy of the criteria that is being used by the insurance company. While this information is proprietary, you have the right to ask and receive this when there are denials for the use of the benefit.
- Asking about the denial.
You have the right to ask why a benefit is denied. Once you understand the terms of the denial, you can investigate the cause of the denial: failure to follow plan procedure, failure to provide a full & fair review, acting as an adversary bent on denying the claim, insufficient reasons for denial, determining a material fact without supporting evidence and/or failure to follow plan procedures.
Feeling more empowered? I hope so. This is just the tip of the iceberg. So this then begs the question: What else can be done?
We live in an era of hopeful change and progress is being made everyday. For your purpose, you can employ various techniques to stay on top of your rights and responsibilities as a clinician or organization working with behavioral health patients.
- Ask questions of the insurance companies.
A nice first place to start is by asking the insurance company more questions when corresponding with them. Get copies of the plan from the start. It helps to first see if the plan has Parity violations within it.
Ask the representative the question “When you make a decision about coverage, do you base it on the terms of the plan?” and if the answer is yes, then your next questions should be: “Are you consulting the plan? and “Where is the plan?”
At the basic level insurance companies are obligated to decide if a patient's benefits exist and/or are not in accordance with the terms of the plan. Many denial letters state that they are denying care based on the terms of the plan, so then it is wise to gain access to the plan and ensure that this is in fact, true.
How do you get the plan? For fully insured plans (individual or large group), the Department of Labor (the government entity that regulates the Employee Retirement Income Security Act- ERISA plans) has issued a rule that all plan documents have to be available online. Unfortunately, self-funded plans are still exempt from this rule. However, did you also know that federal law allows providers, in emergent situations, to be the authorized representative for their patients for purposes of claims and appeals? What does that mean? It means that you are a de facto authorized representative in an urgent scenario, and are able to assert that you are the patient’s authorized representative and that this is an urgent claim/appeal. So, you can be insistent that the plan documents are made available for you online or via email.
- Get involved.
Be part of outreach to major health plans. Join coalitions. Take part in consortiums that work for this exact cause. Network.
- Document, document, document.
Who did you talk to? Date? Time? What was their response? Track your questions as well.
- Educate yourself.
Take part in training and seminars as it pertains to this. Appeal. Advocate. Lobby.
Educate yourself on insurance terms. Health plans are either fully-insured or self-funded. When asking for policy information from the different insurance companies, recognize that fully-insured plans are sometimes called certificates of insurance, certificates of coverage, evidence of coverage. In the self-funded context, plans may be called summary plan descriptions which can be 100 pages or more (not to be confused with the Summary of Benefits of Coverage which is typically five or less pages).
- Educate your patients.
Help the patients understand that they can be their strongest advocates when they call and speak to the insurance companies’ member or customer advocate. In many cases, these advocates take responsibility for helping you navigate the healthcare insurance process as well as understanding your benefits. Encourage the use of this tool.
Kelly Grill-Cooper, MS, LCPC
Kelly graduated from Iowa State University with her Bachelor’s degree in Child and Family Services and her Master’s in Clinical Psychology from Benedictine University in Lisle. She has worked in a variety of clinical positions with various populations including multiple roles in the treatment of sex offenders and working in the chemical dependency field. In addition to this, Kelly has worked in the corrections field, with the homeless population and with wards of the state. In her spare time, she teaches and practices self-care by means of oil on canvas painting.