It’s the best of times in behavioral health…maybe

Perhaps even Charles Dickens might agree that it is the best of times and the worst of times in behavioral health right now. Certainly there’s a revolution going on in the industry, yet for every positive development, there seems to be an equally important caution.

As you know, coverage for mental health and addiction treatment services under all types of benefit plans is increasing, driven largely by the Affordable Care Act (ACA) and parity laws. However, the caution here is that much of the opportunity lies in commercial insurance—including managed care Medicaid—which means there are more administrative hassles and wrestling matches over reimbursement.

You have more patients, and that’s great. But you also have more paperwork, and that’s not so great.

Payers will continue playing hardball as well. For example, they might stop paying if they suspect your organization or nearby providers are submitting fraudulent claims. An administrative misstep might be considered fraud. Or actual fraud by the provider down the street might be identified, and you might suffer an intense audit because of it—guilt by association I suppose.

Sure, it goes without saying that most providers are honest and just want to get their fair, agreed-upon payment. However, many of these good guys still lack the technology backbone to leverage data and keep the pace with payers.

Treatment is not a quick fix

Attitudes about behavioral health conditions are changing. Consumers and lawmakers are rejecting the old-school notion that people can be “fixed” with treatment. As a result, the chronic-care model is slowly coming to the forefront, coupled with the momentum of increased coverage, which has led to increased demand for services. This is a good thing.

But this positive development has also cued some unethical operators who will do seemingly anything for a buck, including coercing the vulnerable into treatment, taking liberties with insurance applications and dumping those in recovery into deplorable living conditions that are billed as sober homes. Again, this is a small fraction of today’s providers, but the taint spreads through the industry as a whole.

State laws are beginning to catch up by essentially requiring certification of sober homes, just as one example, which is now the case in Massachusetts. No doubt we’ll see more of that in the near future.

Make it the best of times

If you want to take advantage of the new opportunities, your best bet is to operationalize and professionalize your business. Consider the technology needs of the back office and how you can leverage such technology to prove your worth. Consider the steps hospitals and physician offices are taking to track and defend their quality. The more you operate like the rest of healthcare community, the better you can move forward with today’s momentum.