Human resources, benefits, and financial leaders - We need your help!
It’s January and for many of us (me included), it will be the first time we put our new health insurance to the test. Unfortunately, many folks who choose to use their health insurance for mental health services will be in for some unfortunate surprises. Here are some I’ve heard from folks who’ve called my practice in the last week:
1. I can’t find any therapists who specialize in what I need help in, who are in-network with my insurance.
2. I thought I had good out of network benefits because it said 60% would be covered. I went to a therapist out of network and I thought insurance would pay $60 and I would pay $40. It turns out insurance only paid $30 and said that was 60% of THEIR allowed amount ($50). Now I owe my therapist $210 because I went three times before finding out how my insurance would actually pay!
3. I work in benefits for my company and I’m desperately looking for therapists to see our employees! I’m so glad you take our insurance. Wait… you’re full? Oh… you and everyone else.
4. My insurance company and therapist agree that I need 90-minute exposure therapy sessions but the most my insurance pays for is 60 minutes. Can they really deny me evidence-based services?
There are a lot of things consumers can do to minimize their insurance surprises but I will talk about that in a later post. Today, I want to make a call to action for people who can actually change this problem for patients who need mental health services: HR professionals, benefits professionals, and CFO’s, I’m looking at you.
No, it’s not fair. Insurance regulators and legislators should have your back in making sure that the coverage you purchased for your employees actually works how the insurance company sold you on it working. However, regulatory and legislative change are slow. Fixing this problem with any speed depends on YOU.
Why should you care? Mental health problems are costing your organization a LOT of money and most insurance companies are lying to you when they say mental health services are getting covered just like any other medical condition.
First, the cost: The true costs of untreated or undertreated mental health issues are hard to measure. You can get your arms around some of it by looking at studies. Partnership for Workplace Mental Health provides stronger data and business cases for why organizations should care about treating their employees’ mental health concerns than I can create independently. Please peruse their Business Case section and Cost Calculators for more information on how these costs may affect you. Data coming from the WHO suggests that every dollar spent on mental health care results in about four dollars of increased productivity. Hopefully I have your attention about why mental health care matters. Now, let’s discuss access to it.
“Yes of course we address mental health! We have health insurance and it covers mental health care,” you say. But does it, really? Your insurance company might be lying to you about providing parity between mental health and physical health coverage. Up until recent years, many health plans excluded mental health coverage from their plans but thanks to various state laws like Oregon’s 2005 mental health parity law and the Affordable Care Act (ACA), insurers now have to cover mental health and meet particular standards of how they do so. To comply, some insurers adopted Coordinated Care Organization (CCO) models that allocate healthcare dollars to mental health care in order to reduce overall spend on health care. Other insurers added mental health care to their benefit plans and outsourced mental health coverage and services to “mental health care management” organizations, incentivizing them to control costs on mental health diagnoses ALONE and not on overall healthcare spend. Still others added mental health care to their list of covered services and started bringing mental healthcare providers in network as any other provider and needed to adjust rates based on their experiences paying for the services.
In fairness to the insurance industry, it was probably a big cost impact to suddenly have to pay for services that were previously excluded from health coverage. The savings from providing people with improved mental health care is long-term and insurance company shareholders care about quarterly and annual performance – not how a company profits in five years, ten years, or a generation down the line. So many companies adopted the following strategies to cope with the increased costs:
1. Decrease reimbursement rates to in-network providers and decreasing “allowable amounts” or “usual and customary rates (UCR)” for out of network services, to levels below what providers in the community were previously being paid.
2. Design plans with no out of network coverage, thus ensuring that all services reimbursed are delivered by practitioners who are both willing to accept rates and medical necessity rules dictated by the insurance company (rationing).
3. Severely limit the number of in-network providers, thus rationing client care using a scarcity of approved providers (“I can’t find anyone in network because the network’s too small or not qualified to treat my condition”).
4. Offer unusable sales carrots to corporate customers like, “No copays for in-network mental health services,” knowing that they have an insufficient network to handle the demand.
5. Bullying providers by denying claims, instituting intimidating medical necessity reviews, burying key terms of provider contracts in difficult-to-access provider manuals, dropping rates after providers are contracted and have clients in-network, and making it difficult for providers to leave the network.
Although physicians and medical providers are certainly suffering from decreasing rates too, most of the techniques listed above are used mostly to limit mental health care alone. Many insurers are getting sued for unfair parity practices but these lawsuits take time and you, as HR, benefits, and finance professionals can make change sooner!
What you can do:
1. Talk with your employees and find out what they need and whether those needs are being met. If you are concerned about getting too personal with them, conduct an anonymous survey to find out how your current coverage is or isn’t working for your employees. If you’re worried that your online survey is traceable and has privacy issues, get employees to type feedback out on paper and put it in a box. You need to learn what they need so you know what to ask for.
2. Identify specific barriers to good care on your insurance plan so you know what to ask for from your broker or insurance company.
a. Can employees easily find someone in-network?
i. If not, they don’t “really” have in-network benefits because they’re not easily useful.
b. Can they afford to use out-of-network benefits? Do out-of-network benefits cover the same or similar dollar amount (allowed amount) as in-network benefits?
i. If out of network benefits pay a fraction of in-network, they’re also not useful.
c. Do employees have necessary skills to negotiate with out of network providers to match or come closer to network rates, thus reducing out of pocket costs for them?
i. Let’s say the “allowed amount” for out of network benefits is $50 per session. If an out of network provider charges $150 per session, your employee can talk with them about accepting less to decrease out of pocket costs.
3. If your company cannot afford an insurance plan with excellent mental health care, consider alternate ways of helping employees pay for mental health care:
a. Set up and contribute to an FSA or HRA specifically for use to fund mental health care.
b. Educate your employees on how to negotiate with community mental health providers for lower rates.
c. Negotiate for your employees with a group of mental health providers who put their name on a list to provide some discounted services to your employees.
d. A local EAP may be able to do some of this for you but if you have a large national EAP, it’s likely they have most of the same problems as large insurers (listed above).
4. Advocate for real mental health access when you purchase benefits. Ask hard questions and demand plans that are structured to provide quality mental health care.
a. If your insurance company has outsourced behavioral health to another organization, warnings flags should go up. Those organizations are not incentivized by improving overall health of your employees but rather by “cost control” of mental health services.
5. Write your legislative and regulatory agencies. Let them know you’re concerned.
In the world of health care coverage, organizations are key consumers and you as HR, finance, and benefits professionals hold the keys to unlock big changes quickly. If you are losing money and productivity because of untreated or undertreated mental health concerns or if you simply want to support your employees to be happier, more effective people in their lives and work, please consider standing up and demanding fair access, transparency, and ethical behavior in mental health. As counselors and as clients, we’re counting on you to help.