July/August 2010 Issue

Managed Care Trends and Mental Health Practice
By Jordana Rutigliano, LMSW
Social Work Today
Vol. 10 No. 4 P. 8

Over the last few decades, sweeping changes in mental health services reimbursement and administration have had a profound effect on the way clinical social workers practice. The increasingly important role of managed care companies in behavioral health has perhaps had the greatest impact. Managed behavioral health care developed in response to rising costs associated with rapid growth in the utilization of mental health and substance abuse services in the 1970s and 1980s. This delivery system was further reinforced when mental health parity was first granted under the Mental Health Parity Act of 1996 (Moniz, & Gorin, 2007). Managed behavioral health care has been a great opportunity for clinical social workers, as their mental health services are increasingly reimbursable. However, with these opportunities have come various new demands.

As a result of the new law and in response to rising costs, clinical social workers in community health centers have faced unprecedented demands in record keeping and billing and have had to assume more responsibility for justifying the need for services. The need for mental health services can be more subjective than the need for medical services, making these requirements more difficult on mental health providers. In the past, authorizations for mental health visits and outpatient treatment reports most often were either not required or could be completed by individuals not directly involved in the care of health center clients.

After the establishment of the Mental Health Parity Act, authorization for mental health services became a necessity because managed care companies were now required to reimburse for mental health services. The companies wanted to ensure that treatment was necessary and as efficient as possible. As a result, managed care companies have established stricter requirements on the authorization of mental health visits and are requesting that mental health providers directly report on client progress to the companies before visits are approved. With the high patient volume in community health center settings and the various requirements established by individual managed care companies, it can be difficult for clinical social workers to incorporate this process into their daily workflow.

Credentialing requirements for clinical social workers are becoming more stringent as managed care companies struggle to cut costs. While mental health parity has increased the amount of reimbursable services provided by clinical social workers, the process by which individual clinical social workers can contract with managed care companies has become more cumbersome. Additionally, it is becoming more difficult for new clinical social workers to become credentialed, as companies are deciding to credential only highly experienced providers. This trend is becoming progressively more problematic as community health centers are often staffed by new social workers trying to obtain their clinical licensure. It also causes competition as health centers try to attract and retain providers who already fit credentialing criteria. In doing so, community health centers may lose the opportunity to screen new employees on the basis of their clinical skills rather than their seniority in the profession and will likely lose out on opportunities to hire talented clinicians.

Facing the Challenges
Managed care challenges such as these, coupled with the current increased demand for services as a result of the economic recession, have caused clinical social workers in community health center settings to become increasingly overwhelmed with the administrative tasks they must balance with their clinical work. Social workers who expect to spend their entire work day in patient care find they also need administrative time to complete authorizations and other forms for reimbursement in a timely fashion. Fortunately, there are options for minimizing these challenges. Clinical social workers can be trained on the documentation required by insurance companies, and they should be encouraged to use the time available from no-show appointment slots to complete their administrative work without cutting into patient care time. The implementation of electronic health records should be explored as an option due to their ability to streamline the billing process and provide automatic reminders to clinicians when a treatment report or authorization is required. Community health centers should also seek support to determine the credentialing requirements for each plan so newer social workers can be credentialed whenever possible as they work to gain further clinical experience. Social workers and credentialing specialists can be referred to individual payer websites for information on credentialing and billing requirements.  

While these managed care challenges can make day-to-day work difficult, social workers should try to face them directly and view the challenges as new opportunities to advocate for clients and the profession as the ethics and foundation of the profession dictate. Authorizations for visits and the completion of treatment reports, while cumbersome, are opportunities for social workers to improve the quality of care to the level clients deserve. These reporting documents encourage clinicians to utilize efficient, evidence-based treatments that enable their clients to improve at a quicker pace and terminate treatment sooner. The reports also provide an opportunity for providers to document the need for long-term treatment for clients with serious and persistent mental illness who sometimes cannot advocate for themselves. At the same time, documentation offers an opportunity for social workers to justify the need for services to managed care companies so social workers will be reimbursed for services in the future. With some uncertainty about the direction of our healthcare system in the new administration, it is important that clinical social workers continue to make the importance of their services known and continue to foster partnerships with the managed care plans for the good of their clients.

— Jordana Rutigliano, LMSW, is the administrative director for the psychosocial services department at the Institute for Family Health in New York City.

Reference
Moniz, C., & Gorin, S. (2006). Health and Mental Health Care Policy: A Biopsychosocial Perspective. 2nd ed. New York: Pearson Education, Inc.