How Can Mental and Behavioral Health Provider Practices Recognize They Are “Being Taken for a Ride”?

"Being taken for a ride" is an expression that means being deceived, tricked, or swindled. It implies someone has been led into a situation under false pretenses, resulting in some form of loss or disadvantage. For example, if someone sells you a faulty product while claiming it's in great condition, you might say you were "taken for a ride." In the context of mental and behavioral health services, provider practices often find themselves in situations where they are being “taken for a ride” by health plans and other entities selling operational support services.

Addressing the issues discussed below requires shared understanding and collaboration among Healthplans, providers’ practices, and regulatory authorities. By advocating for good faith negotiations and fair contract terms, enhanced transparency, and reliable, valid and useful payment models, providers can better protect themselves from being taken for a ride and ensure they can deliver increased quality, and improved health at an appropriate cost.

Here are some specific ways in which mental and behavioral health provider practices are being deceived, tricked, or swindled:

Unfavorable Contract Terms

Many mental health providers find themselves locked into contracts with Healthplans that have unfavorable terms. For example, these contracts may include extremely low reimbursement rates for therapy sessions or psychiatric evaluations, making it financially unsustainable for Providers’ practices to operate. Some contracts may impose limits, directly or by intimidation on the number of reimbursable sessions per patient, limiting the ability to provide appropriate continuing care.

Burdensome Administrative Requirements

Healthplans often impose extensive documentation and reporting requirements on mental health providers’ practices. For instance, therapists may be required to submit detailed treatment plans, progress notes, and/or periodic updates to justify the continuation of care. These administrative tasks can be time-consuming and costly, diverting resources away from direct patient care. Provider practices may also experience frequent audits and requests for additional information, further increasing their workload without corresponding compensation.

Delayed or Denied Payments

Provider practices frequently encounter issues with delayed payments or unjustified denials of claims by insurers. For example, a mental health clinic might submit a claim for a series of therapy sessions only to have the payment delayed for months, creating cash flow problems. Insurers may deny claims based on technicalities or for arbitrary reasons, such as questioning the medical necessity of treatment, forcing providers to spend time and resources on appeals.

Unilateral Contract Changes

Some Healthplans reserve the right to unilaterally change contract terms without the providers’ consent. This may involve altering reimbursement rates, adding new administrative requirements, or changes in the scope of covered services. For instance, a Healthplan might suddenly reduce the reimbursement rate for telehealth sessions, leaving providers with little recourse but to accept the changes or risk losing their contracts or abandoning clients.

Lack of Transparency

Providers often face lack of transparency on the part of health plans regarding payment methodologies, claim-adjudication processes, or criteria used for service authorizations. For example, a psychiatrist might find it difficult to understand why certain medication management sessions are reimbursed at different rates without clear explanation from the insurer. This lack of transparency makes it difficult for providers to anticipate how claims will be processed and paid.

Network Narrowing

Healthplans may narrow their provider networks without adequate notice or justification, effectively excluding certain providers from serving their patients. Narrowing a network disrupts patient care continuity and reduces providers’ patient bases, negatively impacting their revenue. For instance, a psychologist might suddenly find themself excluded from a network, forcing their patients to either pay out-of-pocket or find a new provider.

Risk-Shifting Models

Value-based payment models, while intended to improve care quality and reduce costs, can sometimes shift excessive financial risk onto providers. These models may hold providers accountable for factors beyond their control, such as patient adherence to treatment plans or social determinants of health, without providing adequate support or resources. For example, a community mental health center might be penalized financially if their patients do not show significant improvement, even if that lack of improvement is due to factors such as housing instability or unemployment.

Stealth Utilization Management

Health plans may employ utilization management techniques that are functionally invisible to providers and patients. These tactics may include undisclosed prior authorization requirements, hidden formularies, and/or covert cost-control measures that limit the availability of necessary treatments. For instance, a therapist might discover that a patient's insurance suddenly requires prior authorization for continued sessions, delaying critical care.

Ethical Dilemmas

Providers may be pressured to prioritize cost-saving measures over patient care by contractual incentives or restrictions. This can lead to ethical dilemmas where providers must choose between adhering to contract terms or providing the best possible care for their patients. For example, a psychiatrist might feel pressured to reduce the frequency of sessions or switch a patient to a less expensive medication, even if that is not the best option for the patient’s health.

Lack of Support for Innovation

Innovative care models, such as integrated behavioral health services or telehealth, often lack adequate support from health plans. Providers may struggle to secure reimbursement for these services, despite their potential to improve patient outcomes and reduce overall healthcare costs. For instance, a clinic offering telehealth services may find that insurers are unwilling to reimburse at the same rate as in-person visits, despite evidence of telehealth effectiveness.

DISCLAIMER and PURPOSE: This discussion document is intended for training, education, and research purposes only. The information contained herein is based on the data and perspectives available at the time of writing. It is subject to revision as new information and viewpoints emerge.

For more information see: https://www.mentorresearch.org/disclaimer-and-purpose