4.30.24
今年早些时候,医疗保险中心 & Medicaid 云顶集团 (CMS) took a major step toward improving access to behavioral health care with the launch of the 创新 in 行为健康 Model. 的 model advances the framework for integrated behavioral health (IBH)—a holistic approach to care that emphasizes collaboration between primary care and behavioral health providers. One of the model’s main objectives is to reduce fragmentation and implement new provider payment and incentives for IBH. 尽管这个模型有承诺, 然而, commercial payers have been slower to develop solutions to support providers in IBH.
IBH的工作原理
IBH并不是一个新概念, and integrating physical and behavioral healthcare has long been widely accepted from a clinical perspective as the gold standard of treatment. 的 行为健康模式的创新 aims to propel IBH forward by offering solutions to many of the most difficult operational challenges: health technology infrastructure, 护理管理费用, 以及基于绩效的薪酬. 在这种新模式下, 行为健康环境是切入点, with behavioral health clinicians acting as the leader of the team by initiating assessments, 协调护理团队, 参与护理计划.
Earlier efforts to integrate physical and behavioral healthcare targeted integration in the primary care setting via the Collaborative Care Model (CoCM). This model of IBH utilizes care managers and psychiatric consultants in a supporting role to facilitate behavioral health treatment by the primary care provider. CoCM provides an avenue for identifying and treating low-acuity behavioral health needs within the primary care setting, preserving traditional behavioral health services for patients with more severe behavioral health needs.
While CoCM increases access to behavioral health treatment and promises both clinical benefits and cost savings, 管理——包括账单和付款——是一项繁重的工作. 初级保健提供者负责为护理小组配备人员, 计费保险公司, and then administering payment downstream to the behavioral health care team. 的se tasks are unpaid and require significant time and resource investment from the care providers.
商业支付者缺乏IBH基础设施
CMS anticipates that its new approach will reduce common barriers and inefficiencies within IBH and improve care for the estimated 25% of Medicare beneficiaries experiencing mental illness and the 40% of adult Medicaid beneficiaries experiencing mental illness or substance use disorder (SUD). 商业纳税人, 然而, 尽管对行为健康云顶集团的需求持续增长, continue to lack the financial and operational infrastructure to support providers in their development of IBH programs.
With most large commercial payers still operating behavioral health network operations separately from their physical health network, providers interested in offering IBH programs are left to navigate the complexity of financially connected but operationally disconnected entities. 即使是在单一付款人的情况下, establishing reimbursement for IBH may require obtaining separate provider agreements from different organizations, which involves administrative hurdles starting with initial contracting and persisting throughout the revenue cycle process.
对于许多大型商业付款人来说, steps to obtain an agreement and get paid for IBH services include the following:
- 承包: Behavioral and physical health provider agreements may be administered by separate entities, 每个都有自己的签约代表, 网络应用程序, 证明文件的要求, 处理时间框架. Distinct provider records may need to be created in each provider data management system to hold provider demographic data, 合同信息, 并宣称历史.
- 管理付款人的要求: 每个提供商协议可能有其自己的条款和条件, 由提供商手册补充, 概述供应商参与网络的重要要求. 涉及争议解决的要求, 合同终止, 并及时提出索赔, 等, 可能在身体和行为健康实体之间有所不同.
- 索赔提交和支付: Claims with both physical and behavioral health services may require dual processing by separate 索赔 systems. 为拥有一种健康保险计划的单个成员发放两笔付款, adding complexity to tracking payments as well as identifying and resolving incorrectly paid 索赔. Lack of interoperability between provider data management systems typically precludes payer representatives on the physical and behavioral health sides from collaborating to resolve payment issues, leaving providers to spend many unpaid hours each week resolving payment issues between multiple provider representatives.
让IBH成为现实
Even large provider organizations with dedicated managed care teams struggle to manage requirements, 索赔, and payments across multiple fragmented organizations that are considered part of a single payer. 但随着 超过1.5亿人 居住在指定的精神卫生专业人员短缺地区, 护理的责任不能只落在精神卫生提供者身上. 的 concept of bringing behavioral health providers and PCPs under one common payer program will continue to gain momentum as a means to improve health outcomes and control healthcare spending.
商业纳税人 will need to develop avenues to reduce the deep administrative burden on providers who want to pioneer IBH programs for their patients. This will require payers’ physical and behavioral health business segments—historically operating in silos—to work collaboratively. 进一步, commercial payers will need to mirror CMS’s efforts to fairly compensate and incentivize providers for engaging in IBH.
对心电图
心电图 Management Consultants is experienced in navigating the complex payer environments of physical and behavioral health payer contracting
马特·马斯林编辑