In the U.S. healthcare system, patient needs and healthcare costs are two opposing forces. The most reputable organizations find a way to maximize the relationship between providing low-cost, high quality care, often by making compromises that keep each equally (un)happy.
Behavioral healthcare, however, is a comparatively newer addition to this system, and holds a new opportunity for patient/payer synergy. The passing of the Affordable Care Act in 2010 expanded existing parity laws by mandating and expanding payers’ coverage of mental health services. The relative nascency of these laws means that there is room for the behavioral healthcare field to help leave its mark in informing the standard of care.
Currently, measurement-based care is quickly becoming one such marker of high quality mental health care. At the moment, payers largely view measurement-based care as a practice to be rewarded rather than required.
This is great news.
Demonstrating use of MBC to insurance companies can increase your practice’s revenue. There are three ways this can happen:
1) Get reimbursed for each measurement you administer. Many CPT codes for mental health assessments are underutilized. For example, CPT code 96127 is a billing code for brief emotional/behavioral assessments, such as the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder scale (GAD-7), Columbia-Suicide Severity Rating Scale (C-SSRS), and more. Two other CPT codes to keep in mind are 90801, used when administering a diagnostic interview, and 96146, used to bill for psychological testing administered via electronic platform that provides automatic scoring (like Blueprint). You can find more CPT codes relevant to assessment here.
Reimbursement value varies by payer, but this income adds up over time, especially considering that most payers allow this code to be used several times per session (i.e., once per measure).When a client completes brief behavioral assessments throughout care, adding CPT code 96127 lets payers know that you are practicing measurement-based care and are eligible to be rewarded for it.
2) Negotiate better reimbursement rates in your contracts. Measurement-based care lays the foundation for more favorable contract negotiations in two ways: First, insurance companies respond to objective evidence that patient care is improving. After all, like any business entity, assurance that their return on investment in you is worthwhile for them to continue. And, because insurance companies are rarely staffed by mental health clinicians, having a platform where client data is automatically aggregated will help you speak their language and approach contract negotiations with confidence.
Second, measurement-based care itself provides powerful leverage in improving your reimbursement rates. James Madden, CCO at Seaside Healthcare puts it like this:
“Blueprint allows us to make a better business case to our payers. It allows us to take clinical data and sit with our multiple payers and say ‘We’re doing the thing you’ve been requesting’ and we think you should pay us more because we are different from the average clinic. We have a tool where we can tell how patients are actually responding.”
3) Maximize your preparedness for value-based care (VBC) contracts. VBCs provide a financial upside and downside based on care quality benchmarks defined by the payer. At their simplest, practices are rewarded with bonuses if they meet these benchmarks, or are penalized with decreased reimbursement rates if they don’t.
If this sounds like the holy grail of ROI, you’re exactly right. VBCs are common in other areas of healthcare, but lack of consensus about measuring quality of care in behavioral health has meant that benchmarks differ across insurance companies. Remember the point from earlier about the dearth of mental health clinicians in insurance companies?
Despite these speed bumps, VBCs are on track to show up more and more in your insurance credentialing processes. In fact, the Merit Incentive Payment System (MIPS) uses VBC principles to determine Medicare reimbursement rates based on clinician performance. You can read more about how performance is evaluated here.
Remember, insurance companies want to reimburse you for providing high quality care. By speaking their language - CPT codes and objective data metrics - you help stand out to payers and make it easier for them to reward you. In turn, by practicing measurement-based care, you are actively helping to set the care quality standard for mental health. It’s a return-on-investment that pays for itself many times over.