By SARA ARTHURS
Behind the scenes, the way Ohio mental health care agencies get their bills paid is changing. The hope is that things won’t look very different for individuals receiving care, but there may be some growing pains.
Many people receiving mental health care — and the majority of those in treatment for opioid abuse — receive insurance through Medicaid, which went through a Jan. 1 “redesign” of the services that can be charged for, and how much.
Now, mental health care under Medicaid is transitioning to private “managed care” insurance companies, effective this week.
Mental health and addiction treatment is the last piece of Medicaid being shifted to managed care, said Precia Stuby, executive director of the Hancock County Alcohol, Drug Addiction and Mental Health Services board.
This means mental health care providers will no longer bill the state Department of Medicaid to be reimbursed for treating patients. Instead, they’ll bill one of several managed care companies.
Individuals can enroll in one of these companies, and will be assigned to one if they do not.
Jeff Howell, regional director of clinical services for A Renewed Mind, said Medicaid clients will need to pay attention, as their dentist might be in one managed care company’s network, but their mental health care provider might not.
Those with private insurance have had to look at these networks for years, but that hasn’t been the case for Medicaid recipients, said Julie Weinandy, vice president of medical services for A Renewed Mind, which offers addiction and mental health services on an outpatient basis.
For many years, Medicaid paid health care providers seven days after they submitted an invoice. Several weeks ago, this period went to 14 days, said John Bindas, CEO of Century Health and Family Resource Center. The two organizations announced last year they plan to merge, citing changes in Ohio’s Medicaid as a factor.
As of this week, managed care companies have up to 30 days to pay, which may create cash flow problems, Bindas said. He said once organizations like his get a sense of how long it will take for money to come in, it will be easier to make plans.
For the first year of the transition — until June 30, 2019 — managed care companies must honor existing rates and maintain services. If Medicaid currently pays for a service, the managed care company will have to do the same.
But starting July 1, 2019, managed care companies can negotiate rates and benefits.
After that, “The managed care companies are calling the shots,” Bindas said. “So the contracts might change.”
This means the managed care companies might go longer before reimbursing a provider, or add requirements that are expensive to implement for smaller organizations, he said.
Howell said more than 80 percent of A Renewed Mind’s clients are on Medicaid. About 80 percent of the revenue of Century Health and Family Resource Center comes from Medicaid.
This fiscal year is health care providers’ opportunity to build relationships with the managed care companies, Stuby said. They need to make sure their billing systems “talk to each other.” Instead of one billing system, there will be several, each a little different, Weinandy said.
A change in the Medicaid redesign is that a professional must bill at the highest level they are licensed for. A nurse practitioner, for example, can only be considered a health care provider (just as a physician is) and not a nurse.
This “changed our whole workflow” in both good and challenging ways, Weinandy said.
She said the agency has a larger number of licensed practical nurses, as opposed to registered nurses, which means the agency will be billing at a lower rate.
She’s encouraging the agency’s nurses to go back to school and get their RN degree. Four are currently studying. This will be good for their individual professional development, as well as bring in more money for A Renewed Mind, but will interrupt the workflow while they are going back to school, she said.
Weinandy also said sessions with a therapist had all been “time-based,” such as billing for a 50-minute therapy session.
Now it’s “encounter-based,” meaning the agency gets paid for the number of encounters with patients. She said this may mean a therapist will have to spend less time with each client.
Weinandy said some communications from the state have been confusing. Sometimes the agency thinks it knows what the rules are, only to find out different.
As a nonprofit, A Renewed Mind doesn’t have a lot of money in reserve or savings, Weinandy said. So it will be trying to avoid a situation where it is providing services but not getting paid.
“Our staff have to get paid,” Weinandy said.
Weinandy said managed care companies are more reluctant to contract with smaller organizations. In rural communities, in particular, there’s a concern this may lead to less access to care.
Besides merging, the Family Resource Center/Century Health organization is taking a contract in Shelby County. The goal is to “make us large enough that we’re able to withstand the winds of change,” Bindas said.
A Renewed Mind, meanwhile, is becoming a subsidiary of another organization, OhioGuidestone.
While there are concerns, several of the providers said there will be benefits to the changes.
Stuby said peer support, in which people in recovery help others, could not be billed to insurance before. Now it can.
Another example is “assertive community treatment,” which helps clients like “a hospital without walls,” Stuby said.
“That is now going to be paid for. … That’s big,” said Terry Russell, executive director of the National Alliance on Mental Illness of Ohio.
Weinandy said A Renewed Mind is “not against” the redesign, which the agency sees as “potentially really helping the clients in the long run.”
She said it will be a benefit to have “all health care” — physical and mental — under the same umbrella.
Stuby said clients have had two health insurance cards, one for physical health and one for behavioral health, and this will simplify that system.
Russell sees some positives, but said, “I think there will be bumps in the road.”
He said the most important roles are the care managers assigned to specific clients, to make sure they are well cared for.
“If that doesn’t work, then NAMI Ohio’s going to scream,” and the organization is known for screaming for “people without any voice,” he said.
Lori Criss, CEO of the Ohio Council of Behavioral Health and Family Services Providers, said the group is seeing delays in responses from health plans “despite an all-hands-on-deck approach” from both plans and providers. Her organization sees “red flags” and is concerned the change may stress an already fragile system.
Criss said if any consumers are struggling to get access or are wait-listed, they should communicate with their local ADAMHS board, NAMI Ohio, or Ohio Citizen Advocates for Addiction Recovery.
Stuby said if someone is having a mental health crisis, “always err on the side of safety” and get help. She said if an insurance carrier tries to deny care, people have the right to appeal.
“Don’t assume that you cannot get the service,” Stuby said. “Assume that you can get help.”