Behavioral Health Administrative Workers: What are your employees worth?

A discussion with my coworkers recently reminded me of the wide variability in the size and nature of the organizations that utilize our software products. Behavioral Health organizations range from solo, part-time psychologists, psychiatrists, social workers and professional counselors in private practice to large community-based organizations that provide inpatient, outpatient, intensive outpatient, and home-based care to those requiring mental health and substance abuse treatment.

As a result of this wide variability, the individuals with whom we deal in our provision of technical support services range from highly-trained medical and mental health billing/coding specialists and practice business managers to the teenage child or neighbor of the doctor who happened to be in need of a summer job. We are often amazed by the differences…by how much some billing specialists know and how little information others have.

One of the biggest surprises for me is how often highly trained mental health professionals are willing to entrust their businesses to individuals who have no training to do such a job. We are sometimes asked why our software does not do “x” for them. We explain that the software is a tool to be used by someone who knows mental health/medical billing to accomplish the needed tasks. It will not magically do billing for someone who has no idea how to do that job.

My niece works in a medical practice and is studying for the American Health Information Management Association’s (AHIMA) Certified Coding Specialist – Physician Based exam. I went to AHIMA’s site to see what the content is for this certification and was amazed at the breadth of the knowledge required to achieve the certification. The AAPC is a different organization. . . of professional coders. . . that also offers training, certification, support and networking. Both of these are aimed at individuals who work in medical coding and billing.

Some people who work in behavioral health assume that the billing job must be much simpler for mental health because it contains a much narrower range of services than a general medical practice. Just ask any experienced behavioral health billing specialist, and you will find out that it is not simple at all. Just because the range of services provided in behavioral health is much smaller does not mean that the person doing the billing requires less knowledge about billing and collections and dealing with insurance carriers.

Mental health services were “managed” by insurance carriers much earlier than most other specialties. As a result, there are rules and requirements for obtaining authorization for treatment that have a 30 year history. While “parity” was legislated in 2008 and the final rule for implementation promulgated in 2010, implementation has been slow and many consumers are not even aware that their plan might cover mental health services at the same rate they cover general medical care.

To expect someone who has never worked in a health care setting and has not previously done medical or mental health billing to have any idea about parity or treatment authorizations or copays or coordination of benefits or take-backs is just not reasonable. Medical billing is complicated and behavioral health billing has its own subtleties and complexities that are different.

So what is an employer to do? Here are some quick suggestions:

  1. Recognize that the person who is doing your billing is running a crucial part of your business. You should expect them to be a business professional.
  2. Do NOT expect someone who earns minimum wage to know how to do behavioral health billing. If you find a qualified biller who is willing to work for such a wage, they are selling themselves short.
  3. If your staff is struggling with how to bill, get them information. The Center for Medicare Services (CMS) is an outstanding resource. If a claim will pass Medicare muster, it will also pass the requirements of most other insurers.
  4. Invest in training for your staff. Having your staff thoroughly learn the software product you are using will earn money for your organization.

This is an arena in which I am sure many of you have experience and opinions. Please share your comments below. If you have additional recommendations for employers, please let us know.

Parity Act Slow to Catch On

In January 2011, the American Psychological Association (APA) reported that nearly 90 percent of Americans have never heard about mental health parity or of the Mental Health Parity and Addiction Equity Act of 2008. In a survey conducted for the APA in December 2010 by Harris Interactive, 89% of those surveyed said they had not heard about the federal law that affects people who have health insurance through a group or employer plan. Only 7% even recognized the phrase ‘mental health parity.’

The American Psychiatric Association(aPa) participates in the Mental Health Parity Watchalong with 11 other organizations. This organization is aimed at educating the public about parity, recording and appealing problems experienced by consumers in accessing mental health benefits, and in general facilitating the broad dissemination of information about the parity law. The aPa reportedon it’s intervention with BCBS-IL regarding their new requirements for preauthorizations for mental health treatment. While BCBS-IL rescinded their requirement for 2011, it is this kind of action by insurers that the law was meant to prevent.

Companies like Aetna have added pages to their web sites on mental health parity. These are designed to communicate directly to members and panel providers what positions the company has decided to take relative to the law. This can be an excellent way for consumers who have health insurance to learn how their insurer plans to address the requirements of the law.

As part of the parity implementation coalition mentioned above (Mental Health Parity Watch), the National Council has produced fact sheets and other resources aimed at educating consumers and answering questions about the law. Their are additional resources available on their blog page including summary of the law, FAQ, and a Parity Toolkit.

What has been your organization’s experience with the parity legislation so far? Have you found that insurers are moving forward with equivalent benefits and preauthorization policies for both physical and mental health? If you have run into difficulties, what have they been and how have you handled them.

Please share your experience to date. Thanks for your comments!

Mental Health Parity Toolkit

On October 7 the National Council announced the release by The Parity Implementation Coalition of a toolkit aimed at helping consumers of mental health services deal with their insurance companies. The National Council, a member of the Coalition, has made the 60-page booklet available on their web site. This toolkit is aimed at providers, consumers, and their advocates.

I believe many people expected that the implementation of the Wellstone-Domenici Parity Law would be resisted by payers. Now that the final rule for how to implement the law is in place, there are clear procedures to follow…for the insurers, for providers and for the consumers of care.

This new toolkit includes background information on the law, a detailed outline of the claims appeal process, sample requests for medical necessity determination, templates for letters and detailed instructions about how to use everything in the kit. This looks like a tool that every behavioral health organization . . . community-based and private practice . . . should have on hand to share with clients.

Parity Implementation Coalition members include the American Academy of Child and Adolescent Psychiatry (, the American Psychiatric Association (, the American Society of Addiction Medicine: (, the Betty Ford Center: (, Hazelden Foundation (, Faces and Voices of Recovery (, Mental Health America (, National Alliance on Mental Illness (, National Association of Psychiatric Health Systems (, National Council for Community Behavioral Healthcare (, and Watershed Addiction Treatment Centers (

I think all these organizations deserve our thanks for working together to create the toolkit. Please see page 4 of the brochure for their acknowledgements of sources and people who were involved in the project.

What experiences have you been having relative to parity in your organization? Does your state have additional requirements that must be followed? Do you see a use for this toolkit by your consumers?

Please share your experiences and other comments below.

Managed Care Organizations Oppose Parity

An organization called the Coalition for Parity, Inc. comprised of managed behavioral health organizations (MBHOs) has filed suit to halt the implementation of the Paul Wellstone and Pete Dominici Mental Health Parity and Addiction Equity Act. This group has as some of its members Value Options, Magellan Health Services Inc., and Beacon Health Strategies Inc.

As reported by Open Minds and American Psychological Association Practice Organization, the lawsuit challenges the rulemaking process and has requested a temporary restraining order to stop the rulemaking process from moving forward. They argue that the Departments of Health and Human Services, Labor and Treasury overstepped their rulemaking authority in how they interpreted the statutory language and violated federal rulemaking procedure in publishing the rule as they did. While the judge denied the temporary restraining order because the law will not be enforced until July 1, 2010, the court will hear the case as presented by the parties to the action.

On May 9, 2010, the NY Times reported that insurance companies and employer groups are also objecting to the rules.

In a suit over the rules, Magellan and other companies said the concept of nonquantitative limits was “boundless and ill defined” and would reach virtually every policy and procedure used to manage mental health benefits.

As most mental health providers can readily attest, the procedures used by insurers and managed care organizations to limit costs and usage of behavioral health services have themselves been “boundless and ill defined”; after all, a treatment plan certainly could not be a valid treatment plan if it is printed on the wrong form. The MBHOs have been innovative in their development of “every policy and procedure used to manage mental health benefits.” Unfortunately, most of that management has consisted of denying or limiting the amount of service provided and placing onerous requirements on providers.

The NYTimes article states that:

One premise of the law is that mental illnesses often have a biological basis and can be treated as effectively as many physical ailments. But insurers say it is impossible to use the same techniques in managing the treatment of colon cancer and schizophrenia, or heart failure and major depression.

What do you think? Is it reasonable to assume that mental illness and addiction can be managed using the same techniques as are used to manage the treatment of cancer or heart disease?

Please share your comments below.

Parity Interim Final Rule Guidance Released

On January 29, 2010, the federal departments of Health and Human Services, Labor and Treasury released their “guidance” on the Wellstone-Dominici Mental Health Parity Act. The National Council discussed some of the contents of the Interim Final Rule (IFR) in their February 4 Public Policy Update. The IFR goes into effect April 5, 2010 and applies to policies with plan years that start on July 1 or later.

Since some insurance carriers have already begun changes in their policies and claims filing procedures in an attempt to meet the requirements of law, it is possible that procedures just put in place may be changed. For example, Blue Cross/Blue Shield of Florida, a company that had a limit of 25 sessions per year for psychotherapy with no authorizations required for most plans, in January started to require authorization for all mental health services. According to the information provided by The National Council, this may need to change again.

Group insurance plans for groups of 50 or more may need to carefully match how they manage medical/surgical and mental health/addictions benefits. It is not just the “quantitative limits” that must be the same; the “non-quantitative limit” also must be the same. The IFR forbids plans from using specific non-quantitative limits unless similar restrictions exist for medical/surgical benefits: medical management, prescription formulary design, “fail-first” or step therapies, and prior authorization.

The National Council has continued discussion of the IFR in several articles on their web site. Take a look at their press releases, policy issues and resources, and slides and recording from a recent health care reform webinar. The National Council does a wonderful job of staying on top of and advocating for issues of this sort and should be on your radar all the time.

The American Psychological Association also advocated strongly for this law and information about its implementation can also be found at the APA web site. More detailed and current information about the IFR has been shared with state psychological associations and should be available to APA members who are connected with the practice organization. The email I received through Florida Psychological Association contained a thorough analysis of the IFR along with examples and hypotheticals. A quick read of this article suggests that it will not be a simple matter for a provider or a consumer to determine if their insurance carrier is following the rule. I am hopeful that simpler guidelines will follow.

Dr. Ronald Manderscheid’s article in Behavioral Healthcare Magazine suggests that this law is just the first step in our move toward parity in payment for mental health and substance abuse services. Four other doors need to be opened more widely to assure true parity: 1. the extension of insurance benefits to more individuals and the extension of the rule to more policies; 2. clear statement of what determines medical necessity for access to care; 3. improving scope and quality of the care accessed; and 4. expecting the outcome of care to be at least as good as in the medical/surgical realm. This law brings us a long way toward the goal of equity, but we as advocates have a long way to go to assure that consumers of mental health care can actually get the care they deserve.

What effect do you think the parity law will have on your organization? Do you foresee a big impact or a small change? Please share your comments below.

Mental Health Parity….finally

Based on discussion on the SOS User Forum and comments on our first blog entry, the passage of parity of mental health services with those in the general health arena is a pressing issue for our users. In fact, this is a landmark event in the entire behavioral health community. There is considerable discussion in the newsletter world and in the blogosphere about the final approval of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, a bill that was rolled into the financial rescue package approved by Congress last week. Senators Wellstone and Domenici started work on this bill twelve years ago. Sen. Wellstone was killed in an airplane crash in 2002, but Sens Domenici, Kennedy and others had actively worked for passage of the bill and consider it a major part of their body of work and a tribute to Paul Wellstone.

What will the effect be for providers of mental health services? Will there be differences in effect if you work in the public vs. the private arena? What do you think the impact of this bill will be for your organization? What’s your take on this historic event?

Monica Oss, CEO of Open Minds, indicates that the legislation becomes effective October 2009 and should be implemented by most plans by January 2010. She believes the ramifications will be far-reaching and will occur over the next several years. She suggests the following impacts among others:

  • Behavioral healthcare spending currently misclassified in primary care and emergency rooms will start to be properly classified.
  • Insurance premiums will increase slightly.
  • Funding for mental health and addiction services may be distributed more between public funding and private insurance sources.

Read her entire article at 

Vince posted NPR’s story in his comment yesterday: You can find other stories at;