Mental health providers have long experienced issues with reimbursement from insurers. But in the context of the COVID-19 pandemic, these challenges have dramatically increased.
According to Jennifer M. Doran, Ph.D, president, Connecticut Psychological Association, the issues with insurance are precipitating “an escalating mental health crisis.” Several problematic areas have prompted an onslaught of daily emails with complaints, according to Doran, also an assistant professor at Yale School of Medicine.
To accurately identify the problems areas, an interdisciplinary team, comprising the CPA and Mental Health Clinician Action Network of CT (MHCAN-CT), conducted surveys in spring 2021. The survey responses – 125 from CPA and 456 from MHCAN-CT – revealed significant problems with insurance companies in general, and the most serious issues specifically with Anthem Blue Cross and Blue Shield.
Prior to the pandemic, providers experienced below market standard reimbursement rates, difficulty participating in insurance panels, delayed reimbursement, and other problems. During the pandemic, those issues escalated, Doran explained.
Almost half of the providers reported significant problems in getting reimbursement and more than half reported longer than usual wait times for payment for services, according to the survey.
Additionally, 35 percent of providers said they were receiving demands for clawbacks, some dating back as far as two years.
Sixteen percent of providers were denied reimbursement for telehealth services, which was supposed to be covered at parity during the pandemic, Doran noted.
When providers and/or clients attempted to contact customer service, they spent an hour or more on the phone, according to the survey.
“This is costing the provider hours of time to work on these issues,” Doran said. “Sixty-four percent of psychologists reported that they have had horrible customer service experiences with Anthem. Fifty percent of them have left the panel or are planning to.”
Doran explained that, as an organization, CPA is concerned about what will happen as the number of providers decreases and demand increases. She noted that of the 83 percent of providers were considering leaving Anthem; half are psychologists.
While providers are facing these complications, clients, too, are being affected. “If these problems are causing angst for providers, imagine how difficult it is for clients,” Doran said.
Doran also pointed out that these insurance struggles are seriously affecting patient care. For example, she reported that one provider, who had been seeing a client for 15 years, was recently informed that Anthem would no longer cover the cost of care. The provider was forced to curtail services after providing pro bono therapy for four months.
Another provider whose caseload was full attempted to find a specialist for one of her clients with obsessive compulsive disorder (OCD). The list of 30 “appropriate” providers that Anthem gave her yielded only one social worker who had OCD expertise and was available for a patient referral.
According to Alessandra Simkin, director of public relations, Anthem Blue Cross and Blue Shield in Connecticut, Anthem is aware of the survey and is reviewing the concerns raised.
“First and foremost, Anthem is fully committed to our network of behavioral health providers, and we recognize that they are instrumental in providing our members with access to care during this unprecedented time,” she said.
In terms of reimbursement, Anthem reviews the behavioral health and medical fee schedules on an annual basis, with provider feedback taken under consideration as an important and valued part of that process, Simkin said. “As a result of the review we conducted this year, we increased our rates for behavioral health therapy services by 10 percent, effective August 1, 2021. Providers were notified on July 1, 2021.”
Simkin also reported that Anthem reviewed its claims processing, based on the survey data, and was unable to find any significant concerns regarding claims processing times and denials.
“As it relates to telehealth, the COVID-19 pandemic changed the way people access healthcare, and adoption of telehealth services increased exponentially,” she said. “Throughout the pandemic, we have supported and are complying with the state statute aimed at increasing much needed access for individuals, including waiving member cost share for telehealth visits.”
Regarding claims reconciliation and payment adjustments, Simkin said that Anthem is obligated to customers to ensure that all claims are properly billed and paid under a member’s benefit plan.
“We also screen claims for payment integrity to guard against waste, fraud, and abuse,” she said, adding that Anthem has the right to recover payments from a provider made in error or otherwise make appropriate adjustments to claims.
“This process is governed by law and our provider contracts, and in most cases, there is also appeals process available to providers. If there are ever any questions, we strongly encourage our providers to reach out to us for support.”
Doran emphasized that Connecticut providers are “desperate for change.” She pointed out that these challenges constitute a social justice issue and an access to care issue. “It’s hard enough when insurance works well to navigate the system,” she said. “It’s very challenging [for clients] to find a provider who takes insurance, is not full, and treats your condition.”