REIMBURSEMENT AS A DRIVER OF BEHAVIORAL HEALTH CARE PROVIDER PARTICIPATION

Low reimbursement rates for behavioral health clinicians have been documented across multiple settings, service types, and health care provider types. Three levels of reimbursement disparities have been identified. First, there are significant disparities in reimbursement rates across payers. For example, Medicaid pays, on average, 20 to 30 percent lower rates for behavioral health services than commercial insurance or Medicare, although there is considerable variation in rates across states (Zhu et al., 2023). As one speaker told the committee, “based on data reported to DFR, reimbursement rates for behavioral health services are generally lower than those for medical-surgical services. Despite slight increases seen in reimbursement rates for both categories from 2021 to 2022, the gaps still remain. . . . [A] 30-minute behavioral health visit was reimbursed at $91.55, which is about 130 percent of the Medicare rate. In contrast, a 30-minute medical–surgical visit in the same area was reimbursed at $143.51, representing about 163 percent of the Medicare rate” (Brook Hall, webinar 3 panelist).

Behavioral health professional participation in Medicaid also appears to be among the lowest across payer types, despite Medicaid being the largest payer for behavioral health services (Modi, 2022). A 2017 study found that only 46 percent of psychiatrists were willing to accept new patients covered by Medicaid, while 75 percent of psychiatrists were willing to accept new patients covered by Medicare, and 69 percent were willing to accept new patients covered by private coverage (National Council for Mental Wellbeing, 2022). Several studies and reports have cited low reimbursement rates as a driver of low behavioral health provider participation in insurance programs (Gordon et al., 2018; Mark and Parish, 2024).

Second, particularly for Medicare Advantage and Marketplace plans, behavioral health providers receive higher reimbursement for services delivered out of network than for those delivered in-network (Benson and Song, 2020; Pelech and Hayford, 2019). One study found that for similar behavioral health services, non-psychiatric medical doctors received 13–20 percent higher in-network reimbursement than psychiatrists. However, for services provided out of network, the median reimbursement was 6–28 percent higher for psychiatrists, creating financial incentives that discourage network participation among psychiatrists (Bishop et al., 2014). Third, reimbursement rates largely have not kept up with the cost of care provision, which continues to hurt staffing and services. Figure 5-1 shows the Medicare reimbursement rate for a set of common psychotherapy services over the last 5 years. This reimbursement landscape serves to disincentivize behavioral health care provider participation in insurance programs where behavioral health clinicians have the market power to decide to avoid insurance hassles and earn higher rates with direct cash or out-of-network pay. In addition, there is reimbursement disparity within the Medicare fee schedule. For example, while psychologists and psychiatrists are reimbursed at 100 percent of the Medicare physician fee schedule, the Medicare rate for licensed clinical social workers is set at 75 percent, lower than the 85 percent rate at which other nonphysician practitioners are reimbursed.

FIGURE 5-1

Figure designed by Meghann Dugan-Haas, American Psychological Association Coding & Payment Policy Officer, using data from the CY2024 PFS Final Rule (11/02/2023), Addendum B. CPT Copyright 2024 American Medical Association. All rights reserved. (more...)

There remains a persistent lack of coverage parity for psychiatry compared with benefits covered for medical and surgical services, which tend to be notably higher. Studies have shown that psychiatrists are reimbursed about 20 percent less than primary care physicians for the same set of services (Rapfogel, 2022). While the Medicare Improvements for Patients and Providers Act of 2008¹ implemented cost-sharing parity between outpatient behavioral health services versus all other Part B services, federal parity laws such as the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)² apply to Medicaid Managed Care and commercial health plans but do not apply to Medicare q, 2016a). As a result, behavioral health benefits can be more restrictive in Medicare than in other services. For example, Medicare has no lifetime limits on inpatient services other than those for psychiatric hospitals (Freed et al., 2023). Similarly, there is often a lack of parity when comparing substance use disorder (SUD) with mental health treatment services. While mental health and substance use conditions are often co-occurring, services may be provided in different settings, by different care providers, using different billing codes. For example, coding for schizophrenia in an encounter could substantially increase reimbursement, even if substances were causing the psychosis (Zhu et al., 2022). There is concern that this separation creates barriers to coordinated care and contributes to continued and longstanding fragmentation of care in delivery systems.

Payment also inadvertently disadvantages health care providers who are delivering more complex or prolonged care, language translation, and care coordination. For example, translation services for a therapy appointment generally cost more than the reimbursement rate, and using a translator lengthens the appointment duration. A minority of states and territories cover language services for language-incongruent visits. In at least 14 states and the District of Columbia, Medicaid and the Children’s Health Insurance Program (CHIP) reimburse health care providers or language service agencies for the cost of interpreter services (APA, 2020) but require care providers to enroll in these services and complete additional paperwork in Medicare and Medicaid which may not be required in commercial plans. Overall, 16 percent of nonelderly adults living in households with at least one Medicaid enrollee have limited English proficiency, compared with 7 percent of nonelderly adults in which no household member is enrolled in Medicaid (Haldar et al., 2022).

State behavioral health workforce reports have replicated these various payment disparities and the perceptions of and effect on behavioral health care providers. Key informant interviews with behavioral health providers and provider organizations in Washington, Oregon, California, Minnesota, Illinois, Texas, and other states demonstrated agreement that behavioral health provider wages and reimbursement is a key issue in the recruitment and retention of clinicians to the field of behavioral health more broadly and in driving attrition specifically from public payer systems (Department of State Health Services, 2014; Gattman et al., 2017; Mental Health Workforce Steering Committee, 2015; Post, 2019; Zhu et al., 2022). Behavioral health care providers across states perceive current reimbursement rates to be not commensurate with behavioral health providers’ level of education, experience, or skillsets. Finally, wages vary widely across behavioral health occupations, as do the settings in which people are employed. Paula Stone, director of the Arkansas Department of Human Services, Office of Substance Abuse and Mental Health, reported in webinar 3:

What we didn’t have was something similar to what we saw on the commercial insurance side, which was independently licensed master’s degree professionals that would be able to provide counseling services and set up pretty much more like private practice kinds of situations. So we . . . began paying them in 2018 the same rate we were paying agency providers. . . . (W)e went from about . . . less than five providers statewide to well over 400 of those providers statewide when we opened that up.

One of the things we really wanted to do was to allow those kinds of professionals that had private practices out across our state is, not only would they enroll in commercial insurance networks, they would also start taking Medicaid clientele.

Others have found efforts to retain a diverse, culturally competent workforce to be challenged by payment concerns. A report from the National Council for Mental Wellbeing (2022) identified pay as the main barrier to recruitment and retention of qualified behavioral health staff. This was especially true for health care providers of racial and ethnic minoritized groups, with concerns about race-based pay inequities further exacerbating low wages. Although it is important to have a diverse workforce with equitable pay, it is necessary to emphasize that the goal should be for all providers to be culturally competent, and not just rely on the racial and ethnic minority providers to solve the problem of health disparities.

Research eliciting behavioral health provider perspectives on reimbursement is limited, and empirical evidence regarding the effect of higher reimbursement rates on care provider participation in insurance markets is mixed (Candon et al., 2018; Saulsberry et al., 2019; Wagenschieber and Blunck, 2024; Yu et al., 2019). A recent Government Accountability Office (GAO) study noted when state Medicaid programs increased payment rates for substance use treatment, states saw a marked increase in supply (GAO, 2020b).

Other research on the effects of reimbursement increases has largely been limited to primary care or dental care. Some studies have focused on evaluating the effects of the temporary Medicaid fee bump for primary care clinicians in 2013–2014 under the Affordable Care Act (ACA). One study found that a $10 increase in Medicaid reimbursement was associated with 13 percent fewer enrollees reporting difficulty in being accepted as a new patient and a 1.4 percent increase in the probability that enrollees reported an outpatient visit in the past 2 weeks (Alexander and Schnell, 2019). However, other studies have found no significant association between primary care fee changes and Medicaid participation (Decker, 2018; Saulsberry et al., 2019). One study, using 2010–2016 data, found that a $10 increase in primary care fees reduced the probability of a positive screen behavioral illness by 2.8 percent among adults (Maclean et al., 2023).

While there is an absence of empirical evidence on the effects of reimbursement increases on behavioral health provider participation rates, there have been efforts at both the federal and state levels to increase payments. In a recent survey of state Medicaid programs, 38 of 44 responding states reported increasing reimbursement rates in 2023 or having plans to increase reimbursement in 2024, though there was wide variation in the scope and magnitude of these changes and the extent to which they applied to specific versus broader behavioral health provider groups (Saunders et al., 2023b). For example, Iowa’s Medicaid program reported a 20.6 percent increase in rates for behavioral health intervention providers in fiscal year (FY) 2023 as well as a 56.6 percent increase in rates for individual mental health practitioners and a 96.5 percent increase in rates for SUD providers in FY 2024 (Hinton et al., 2023). In comparison, Vermont reported a 5 percent and 8 percent rate increase for SUD and behavioral health providers, respectively, in FY 2023, followed by another 5 percent rate increase across all behavioral health providers in FY 2024.

In addition, Medicaid managed care plans have several tools, including the use of supplemental or directed payments, to target specific behavioral health provider types or services where a lack of access violates existing network adequacy standards (Candon et al., 2018). In Medicare, CMS has recently proposed or implemented several payment-related changes for behavioral health services, including increasing rates for SUD treatment in the office setting and increasing rates for some timed services such as psychotherapy (Hinton et al., 2023; Seshamani and Jacobs, 2023). CMS will also increase reimbursement for psychotherapy for crisis services to pay 150 percent of the usual Physician Fee Schedule rate when this care is provided outside of health care settings.

In webinar 3, Sean Robbins, the executive vice president and chief corporate affairs officer at the Blue Cross Blue Shield (BCBS) Association, reported some BCBS plans for increasing reimbursement by as much as 50 percent, reporting: “We’ve been able to increase the Blue Cross and Blue Shield behavioral health networks by over 55 percent over the last 4 years, with coverage in all 50 states.” However, Robbins also said that rate increases did not address low provider participation: “While payment is an important factor, it is not sufficient,” he said. “It is not enough alone . . . it simply doesn’t do enough to solve the issue of building broad networks. . . . It does not equal network participation.”

However, at webinar 2, Rakhee Patel, the regional adult services clinical director at Coastal Horizons Center in North Carolina, voiced a different opinion: “Here in (our state) we have not had rate increases for behavioral health care in over 12 years for Medicaid programs. That is huge. . . . The reimbursement rates for Medicaid and even some of the private plans . . . have been really grossly inadequate for . . . what our clinical psychiatric staff do. Therefore, that really does disincentivize providers wanting to opt in to seeing these Medicaid and Medicare beneficiaries.” Low in-network rates are consistently raised in the literature as an important barrier to insurance acceptance for behavioral health providers. Anecdotal and empirical evidence is inconclusive about the scope and magnitude of reimbursement increases needed to induce behavioral health provider participation in insurance programs. Further evaluation of these ongoing efforts and their effects is needed.

Coding and Behavioral Health Provider Eligibility Concerns

Behavioral health providers’ concerns regarding reimbursement are not limited to low reimbursement rates and include disparities in reimbursable services across provider types, care settings, and payers. Because reimbursable behavioral health services require a preceding diagnosis, therapeutic appointments lacking a diagnostic code for a mental health issue or SUD are ineligible for payment, compared to primary care where preventive or wellness visits are reimbursed (CMS, 2019, 2023e; Dormond and Afayee, 2016). In addition, substantial differences exist across Medicare, Medicaid, and Marketplace plans in the coverage and reimbursement of core behavioral health services, including many that add clinical value to patients and are performed within appropriate scopes of practice. These differences not only create administrative, payment, and clinical inconsistency among health care providers, adding to operational burdens, but they also directly limit access to certain types of services and health care provider types across payer populations.

Both Medicare and Medicaid recognize psychiatrists, clinical psychologists, LCSWs, and APRNs/nurse practitioners as core behavioral health professionals who can bill for common Current Procedural Terminology (CPT) codes (Dormond and Afayee, 2016). Starting January 1, 2024, marriage and family therapists (MFTs) and mental health counselors (MHCs) may independently bill Medicare for their services (CMS, 2024c). Implementing Medicare eligibility for MHCs and MFTs is estimated to increase the behavioral health workforce by about 225,000 care providers nationally and expand much-needed access to behavioral health services for Medicare beneficiaries.

Medicaid billing processes and procedures also vary from state to state, particularly in reimbursement for clinical psychologists, LCSWs, MFTs, MHCs, and peer counselors (Dormond and Afayee, 2016). Peer support services, in particular, remain an optional benefit for state Medicaid programs (GAO, 2020a), although as of 2023, 48 states covered peer support services in their Medicaid fee-for-service programs. Per a 2022 Kaiser Family Foundation report, 16 states specify service limits, such as units per day or medical necessity (KFF, 2022). Some variation in behavioral health provider billing eligibility stems from differences in scope-of-practice laws at the state level. For example, Louisiana, New Mexico, Illinois, Iowa, Idaho, Colorado, and Utah permit doctoral-level psychologists to prescribe or consult for medical doctors after receiving specialized training (DeAngelis, 2023). Thus, varying behavioral health provider roles and scopes of practice may contribute to some heterogeneity in billing eligibility and coverage. A study done by the University of Michigan’s School of Public Health highlighted the challenges in meeting the demand for mental health and substance use disorder services due to a shortage of qualified professionals. The study suggests further efforts are needed in reviewing billing and reimbursement practices and the assurance of reimbursement for routine procedures within professionals’ expertise. It also explored how professionals use CPT codes across Medicare, Medicaid, and private insurers, noting that while most codes are usable for authorized services, alternatives exist for restricted codes (Dormond and Afayee, 2016). Tables 5-1 and 5-2 show Medicaid program variation between states in behavioral health care provider eligibility for billing common behavioral health services. Misalignment in reimbursement can hamper coordinated care efforts, although as healthcare moves towards integrated and value-based models barriers may diminish as payers value the benefit of non-licensed professionals and team-based approaches, leading to better patient outcomes with possible savings of cost (Dormond and Afayee, 2016).

TABLE 5-1

Medicaid Reimbursement Eligibility for 90791: Psychiatric Diagnosis Evaluation without Medical Services, by State and Occupation.

TABLE 5-2

Medicaid Reimbursement Eligibility for 90846: Family or Couples Psychotherapy with Patient, by State and Occupation.

RISING COSTS MAY RESTRICT NEEDED INVESTMENT IN WORKFORCE: THE ROLE OF COST CONTAINMENT

With ensuring patient access to quality care as the overall goal, there are numerous competing focuses that deserve attention within Medicare, Medicaid, and Marketplace plans. Focus on rising costs and potential service delivery efficiencies while improving outcomes, demands serious policymaker attention on reasonable and evidence-based cost containment measures. It cannot be understated that cost containment measures are simultaneously (a) critically important to the fiscal sustainability of Medicare, Medicaid, and Marketplace plans and (b) having a dramatic adverse impact on the provider experience in the provision of care. As this report discusses “Administrative Barriers” and “burdens” throughout its chapters and recommendations, the Committee recognizes that cost containment tools (such as prior authorization) are fiscally necessary, and to a large extent will continue to be applied. However, the Committee also identified the often-excessively time consuming and ineffective application of these cost containment tools. The need to reform current cost control mechanisms to ensure their most effective, accountable, and targeted application is identified as an area of immediate action.

ADMINISTRATIVE BARRIERS

As a child and adolescent psychiatrist, when there had been stimulant shortages in the past year . . . covered by Medicaid and CHIP . . . I needed to get a prior authorization for another medication; by the time I got the prior authorization, the medication was already out. I had to pursue another prior authorization . . . spending the valuable time as a provider trying to take care of people and kids. It delayed actually access to care, but it also increased the level of stress and additional work and burden on the psychiatrist if you do not have a practice management system that takes care of all of those things.

—Warren Ng, webinar 2 panelist

Experiences of Behavioral Health Care Providers with Public Insurance Programs

Health care provider administrative burden consists of an array of time-consuming requirements, including prior authorization, payment denials and associated appeals, and other added costs of doing business. A large body of work has shown that the time and expense associated with these paperwork and negotiation activities influences the decision of health providers to participate in insurance plans, particularly Medicaid. There is also concern that administrative processes, including prior authorization, may be one way that health plans may limit access to behavioral health services in particular. While behavioral health providers face many of the same administrative burdens as medical and surgical providers, there are also administrative burdens unique to behavioral health. For example, behavioral health providers remain more likely than medical and surgical providers to work in small-group or solo practices, with limited capacity and support for billing, claims processing, network contracting and credentialing, and other administrative activities across the modern clinical practice continuum. In addition, the organization of behavioral health service delivery may impose unique burdens on the workforce. For example, 43 percent of psychologists outside of urban areas operate in solo practices, and 11 percent work in independent group practices and 43 percent in individual solo practices (Hamp et al., 2016). As such, behavioral health providers often lack the administrative staff needed for administrative and operational tasks, including paperwork required to enroll in provider networks, maintain credentialing, coding, reimbursement, and appeals processes.

Supporting this evidence, behavioral health providers responding to the committee’s RFI said they perceived several administrative processes to be overly burdensome, including prior authorization processes for medication and service coverage; addressing claim rejections; lengthy and document-heavy credentialing processes; and documentation burden to comply with audits, including the real or perceived threat of insurance clawbacks (Pollitz et al., 2023c). Other data drawn from the multi-specialty physician members of a large academic medical center found administrative burden to negatively affect the behavioral health care provider experience in an academic setting. Physicians in this sample said that they spent nearly a quarter of their working hours spent on administrative tasks, and higher administrative burden was associated with higher burnout and lower career satisfaction. The administrative tasks identified as most burdensome included prior authorizations and ambulatory clinical documentation (Rao et al., 2017).

Primary issues with these insurances are generally related to coverage and pre-authorizations . . . . I am paneled with some Medicare and Medical plans that are easy to work with and others we struggle to obtain authorization for services even with providing solid clinical evidence and support.

—Ph.D./ Psy.D.

Private medical clinic, UT

Billing and Coding Barriers

Delayed and denied payment is a key factor influencing behavioral health provider participation, particularly in managed Medicaid and Medicare Advantage. Beyond reimbursement rates, payment-related administrative barriers may include paper-based billing, processing errors, payment denials, and time-consuming negotiation and appeals processes. Evidence demonstrates that physicians report payment delays and other administrative burdens associated with Medicaid in particular and that delays in reimbursement can offset the effects of rate increases (Cunningham and O’Malley, 2008). Along these lines, there are several major effects of administrative barriers on behavioral health care providers’ willingness to accept insurance.

• Care providers respond to billing problems by refusing to accept Medicaid patients. Empirical evidence suggests that payment hurdles appear to be as important quantitatively as payment rates in explaining the variation in physicians’ willingness to treat Medicaid patients. Health care provider reluctance to accept Medicaid is acute in states with more billing challenges (Dunn et al., 2021). A 2024 analysis of national remittance data found that care providers lose 18 percent of Medicaid revenue to billing barriers, compared with 4.7 percent for Medicare and less than 2.4 percent for commercial insurers (Dunn et al., 2021). The same study found that increases in incomplete billing reduced the probability of physicians’ acceptance of Medicaid to a larger effect than a comparable increase in Medicaid reimbursement rates, suggesting the importance of administrative hassles in influencing willingness to participate in Medicaid (Gottlieb et al., 2018).
• Lag times in reimbursement generate financial uncertainty. Payment for services through Medicare and Medicaid may occur several months or more after the clinical encounter. The numerous, complicated, and highly specific steps in the revenue cycle increase the likelihood of errors, both by payers and care providers (Burks et al., 2022). For example, an incorrectly entered initial or digit may often result in a denial. Once corrected, re-submission of the claim may yield yet another denial, this time for timely filing. The delays and lack of predictability in cash flow represent a significant source of financial uncertainty for care providers and provider organizations (LaPointe, 2016). In Medicare Advantage the Department of Health and Human Services (HHS) Office of the Inspector General (OIG) has found evidence of inappropriate payment denials that exacerbate health care provider cash-flow challenges. Medicare Advantage plans were found to deny payments to health care providers for services they had delivered to patients, even though the requests met Medicare coverage rules and Medicare Advantage organization billing rules. Physicians were more likely to fight a denial when the reimbursement rates and the likelihood to collect payment are higher, but this effort is time and labor-intensive, which could adversely affect behavioral health providers practicing in smaller and independent settings.

Respondents to the committee’s RFI noted the effect of such administrative burdens. For example, once a care provider had been admitted to insurer panels, documentation expectations were reported to be “very rules-heavy” and administratively complex with limited assistance in navigating or understanding policies, procedures, and processes. Some health care providers reported that after a prolonged waiting period, claims could be denied if even a small detail was missing or erroneous. Many reported they needed to hire a full-time administrative staff to manage authorization and billing processes, especially in Medicaid, and that the process was such that the costs exceeded the generated revenue. Some respondents felt they were paying to provide the service instead of being paid. Finally, several health care providers expressed concerns that if they were treating a higher-than-average number of Medicare and Medicaid patients, they would be flagged as being potentially fraudulent and risk being audited, a process that was both time consuming and financially draining.

Given that delays in Medicaid payments reduce care provider participation, some Medicaid agencies have adopted prompt payment policies (Cunningham and O’Malley, 2008). Box 5-2 highlights the rules for prompt payment. The GAO’s examination of Medicaid program integrity found that collaboration between CMS and state auditors engaged in Medicaid oversight could help target oversight to areas of greatest risk for noncompliance such as lags in prompt payment (GAO, 2023). In addition, some Medicaid agencies are incentivizing behavioral health providers to participate in integrated physical and behavioral health systems (Saunders et al., 2023a). Similar policies exist across commercial and Medicare Advantage plans, but there is evidence that inconsistent or non-specific definitions allow insurers wide latitude in interpreting what constitutes a “clean claim” and make it possible for them to reject claims for minor mistakes or to use other tactics to dictate the payment timeframe. Additional reasons for insurers to deny a submitted claim, such as not a covered benefit or enrollee, no prior authorization approval or referral, or a medical necessity concern, also contribute to delays. To a health care provider, these denials could lead to the same time-consuming, back-and-forth negotiations and appeals that effectively constitute a payment delay (Pollitz et al., 2023a).

BOX 5-2

Prompt-Pay Rules.

Prior authorization and related usage review tools such as concurrent review are management tools that insurers use to determine what behavioral health care provider-recommended services or medications for a particular patient they will approve for payment. Most prior authorizations are typically done either by telephone or via electronic web portals (ACMA, 2021). After submitting the required information, the payer may approve the prior authorization, approve it with revisions or limitations, or deny it. Health care providers and patients may appeal denials through an established review process involving the submission of further documentation. These processes are ubiquitous. In 2024, Medicare Advantage plans required prior authorization for up to 21 percent of all clinical services, including 93 percent of all Part B medication spending and 74 percent of all medication use (Gupta et al., 2024). An OIG report reviewing 115 Medicaid managed care plans found that in 2019 one out of every eight prior authorization requests were denied (OIG, 2023). A 2018 study showed that 85 percent of Medicare Advantage plans imposed prior authorization processes on psychiatric services, compared with 60 percent for other physician specialty services (Hodgkin et al., 2018).

There is ongoing debate about the role and efficacy of the prior authorization process. Insurers maintain that prior authorization is a necessary cost control mechanism to address inefficient or unnecessary spending, low value or harmful care, and misalignment of health care resources. According to an April 2023 analysis, inefficient clinical spending costs an estimated $345 billion a year (Peter G. Peterson Foundation, 2023). The pressure to reduce the costs of inefficient or ineffective care compels insurers to weigh the savings associated with decreasing inefficiencies with the cost of doing usage review or management. These usage review practices generally consist of reviewing a practitioner’s clinical judgment and clinical plans to determine if services should be reimbursed. Some evidence suggests that prior authorization processes may reduce costs. For example, a 2023 study examining prior authorization restrictions in relation to prescription drug use and spending in Medicare Part D found that the use of prior authorized drugs declined by 25 percent and overall Part D spending fell by 3 percent, translating into savings that exceeded the overhead costs of administration by a factor of 10 (Wallace, 2023).

In behavioral health, prior authorization is used to manage the array of SUD inpatient and outpatient treatment services. Some insurers focus prior authorization only on residential SUD treatment out of a concern for cost and quality (Tufts Health Plan, 2024). However, for individuals in crisis and for those who are committed to seeking treatment, a delay in care can be catastrophic and can contribute to missed opportunities for early treatment, poorer outcomes, or foregone care. Other common applications of prior authorization in behavioral health care include mental health partial hospitalization programs, inpatient detoxification admissions, mental health inpatient admissions, neuropsychological testing, psychological testing, behavioral health day treatment, residential treatment, and electroconvulsive therapy, though these applications vary widely across plans and markets.

Health care providers note that significant time and labor demands are required to comply with prior authorization processes (AMA, 2022b). A 2009 study estimated that physician practices spent, on average, 20.4 hours per physician per week to respond to authorization requests, the second greatest administrative burden after billing. These prior authorization processes are viewed as having a cost-shifting effect onto the health care provider, by demanding additional provider time and staff resources to comply with them. In response to a 2017 American Medical Association survey, 34 percent of physicians reported having at least one staff member working exclusively on prior authorization requests, representing a substantial added cost to each practice that is not calculated into estimates of the cost–benefit of prior authorizations (AMA, 2018; Casalino et al., 2009).

Thus, the potential benefit of prior authorization processes in reducing unnecessary or wasteful spending is offset by the significant associated administrative burdens and costs to the insurer and provider of conducting prior authorization processes and is offset by the costs to the patients of dealing with the effects of delayed patient care. More recent evidence suggests that prior authorization processes play an important role in insurance participation decisions. Reducing provider hassles could promote greater provider participation, which may be as important as containing unnecessary spending. One study found that when administrative burdens are disproportionately greater in Medicaid programs, relative to other payers, providers are more likely not to accept Medicaid insurance (Dunn et al., 2021). These findings have been replicated in other settings. For example, a 2011 survey of Washington State primary care physicians found that a quarter of physicians already seeing Medicaid patients considered administrative paperwork in Medicaid to be a major problem. Consistent with other studies, these researchers concluded that there is a care provider financial calculation related to the practice costs of participation in Medicaid (Long, 2013). Another study showed that the requirement of prior authorization for certain medications has been cited as a top reason by psychiatrists to decline participation in Medicare and Medicaid provider networks (Shim et al., 2014).

Evidence suggests that prior authorization processes may prevent individuals with behavioral health needs from obtaining needed services because of delay or coverage uncertainty, sometimes leading to untreated disorders. A 2022 survey of physicians by the American Medical Association found that 94 percent of physicians reported care delays arising from prior authorization requests and 80 percent reported that prior authorization processes sometimes led to the abandonment of the care plan (AMA, 2022a). A 2023 Kaiser Family Foundation consumer survey found that more than a quarter of those seeking treatment for behavioral health conditions had experienced prior authorization problems in the previous year, compared with 13 percent of insured adults who did not seek behavioral health treatment (Pollitz et al., 2023b).

Similarly, a GAO report found that prior authorization is less likely to be granted for mental health inpatient hospitalizations than for medical and surgical hospitalizations, creating further access challenges for patients who need acute and higher levels of service (GAO, 2022). Evidence also suggests prior authorization policies, as well as step therapy and other use management requirements, measurably affect behavioral health medication choices as well as medication continuity (Zhang et al., 2009). Research has also shown that increased hospital and other health care service use is linked to delaying or switching psychiatric medications due to prior authorization and other medication management tools (Lu et al., 2011; West et al., 2010).

Removing prior authorization for certain behavioral health services has been shown to promote access to evidence-based treatment and improved outcomes, while significantly decreasing adverse outcomes such as related hospital use. A notable share of policies to remove prior authorization in behavioral health have been part of a bundle of state policies designed to expand the use of medication-assisted treatment (MAT) for opioid use disorders (OUDs). For example, removing prior authorization for MAT among Medicare patients with OUD was associated with a decrease in opioid use, an increase in MAT initiation, a significant decline in relapse rates, and decreases in SUD-related inpatient admissions and emergency department visits (Mark et al., 2020). Studies of Medicaid-funded OUD care found that prior authorization was linked to lower use of buprenorphine prescription, an evidence-based MAT option, in addiction treatment programs (Andrews et al., 2019). Finally, the effects of prior authorization removal may differ in different contexts, an area needing further study. An analysis of Medicaid beneficiaries found that states with low baseline MAT use had significant increases in usage associated with the removal of prior authorization processes, but that this effect did not exist in states with already high baseline MAT use (Christine et al., 2023).

Studies of insurer application and government regulation of prior authorization activities suggest a need for enhanced regulatory oversight. The HHS OIG found that Medicare Advantage plans improperly denied 13 percent of prior authorizations for services that Medicare should have covered (OIG, 2022). The same review found extensive use of prior authorization in Medicare Advantage plans, including prior authorization for 99 percent of Part B drugs, versus traditional Medicare, which generally does not use either prior authorization or step therapy for Part B drugs. OIG also noted excessive documentation requirements and clinical ambiguity. Among Medicaid managed care organizations, OIG found high rates of denied prior authorization requests, insufficient oversight by most states of prior authorization denials, and limited access to external medical reviews to expertly determine care approvals.

While offering consumer choice and potentially competition among plans, state contracting with multiple Medicaid managed care organizations appears to increase provider administrative burden. Unless a state requires standardization, health care providers contracting with multiple Medicaid managed care organizations encounter duplicative administrative burdens which could challenge smaller behavioral health organizations in particular. When a state contracts with multiple MCOs healthcare providers need to sign agreements with each one to join their networks. This requires managing several contracts, adhering to diverse administrative rules, and adjusting to different reimbursement rates. These complexities can challenge care coordination among the various MCOs leading to increased administrative burdens and potentially affecting the efficiency of healthcare delivery. In addition, OIG found that managed care organizations in many markets violate federal MHPAEA requirement that insurers’ prior authorization requirements and medical necessity standards for behavioral health services must be comparable to, or “no less restrictive” than, those for medical and surgical health services (OIG, 2023). Finally, as with Medicaid managed care organization markets, state insurance regulator, CMS, and Department of Labor reviews have found commercial plans, including Marketplace plans, with MHPAEA parity and other violations resulting from impermissible preauthorization requirements and improperly denied claims.

Based upon patient and behavioral health provider pressure, negative feedback, and state 699 legislative and regulatory actions, efforts are underway to streamline prior authorization 700 processes. In 2024, CMS issued a final rule aimed at expediting and automating prior authorization processes for medical items and services (other than drugs) in Medicare Advantage (MA), Medicaid, Children’s Health Insurance Program (CHIP), Medicaid and CHIP managed care organizations, and Qualified Health Plans (QHP) offered through the Federally-facilitated Marketplace. These final rule provisions, largely beginning in 2026, also include requirements to publicly report prior authorization metrics, such as approval rates and median length of time to make a decision. In addition, state Medicaid programs are working to address “administrative burdens to reduce time associated with unbillable (sic) behavioral health provider time and resources and potentially result in higher rates of Medicaid acceptance” (Saunders et al., 2023a). Box 5-3 highlights a recent Kaiser Family Fund study on what some state Medicaid programs are doing to increase participation of behavioral health care providers.

BOX 5-3

Review of State Innovations Aiming to Increase Behavioral Health Provider Participation in Medicaid.

Although progress to address commercial insurance, including Marketplace plans, has been slow, a January 2018 agreement among national insurance and behavioral health provider associations resulted in a “Consensus Statement on Improving the Prior Authorization Process,” which highlighted the need for various approaches, including:

• Selectively applying prior authorization requirements, exempting certain care providers based on their quality performance (called “gold carding”) (AMA, 2024).
• Using data analytics and clinical criteria to reduce the list of services subject to prior authorization.
• Communicating prior authorization requirements, criteria, and rationales to care providers and patients.
• Using electronic health records or other automated systems for electronic prior authorization versus phone and fax processes.
• Ensuring continuity of care for patients undergoing active treatment with change of coverage.
• Enacting laws limiting prior authorization from public and private insurers on SUD services or medications, something that 21 states and the District of Columbia have done since 2020 (Partnership to End Addiction, 2020).

Pathways to Enrollment in Medicare, Medicare Advantage, Medicare Marketplace, and Medicaid Plans

Providers who wish to participate in Medicare, Medicare Advantage, Medicaid, and Marketplace plans must become acutely familiar with the requirements and steps involved with each specific plan. CMS offers two options for enrollment – one for individual providers and one for organizations. Regardless of option, enrollment for Medicare, Medicare Advantage, and Marketplace plans typically follows three main steps to becoming a Medicare Provider: (1) Obtain a National Provider Identifier (NPI), (2) Complete the Medicare Enrollment Application, and (3) Work with regional Medicare Administrative Contractor (MAC). Individuals must complete the enrollment steps on their own, whereas organizations typically have enrollment and credentialing staff who manage applications. The enrollment process typically takes 60–90 days. CMS offers multiple resources, including videos, on how to enroll in Medicare (CMS, 2023a). Figure 5-2 shows a summary of the enrollment process for Medicare providers and suppliers.

FIGURE 5-2

Enrollment process for Medicare providers and suppliers. SOURCE: Schalm and Chong, 2024.

Provider participation in specific Medicare Advantage and Medicare Marketplace plans will have to complete additional application steps for each plan (Freed et al., 2024).

In contrast to Medicare, Medicaid programs are state based and fall under the purview of individual state Medicaid agencies (CMS, 2016; Medicaid.gov, 2024). As such, each state has its own application procedures. In general, any provider seeking to participate in a state Medicaid program must submit demographic information (including social security number), licensure, National Provider Identifier (NPI), and any criminal convictions related to Medicare, Medicaid, or CHIP (CMS, 2024a). If the provider practices in one of the 41 states that has Medicaid Managed Care (Hinton and Raphael, 2023), they must also complete additional applications to each Medicaid Managed Care entity. For some providers, this could result in as few as two additional applications (e.g. As noted previously, the majority of behavioral health providers in independent practice do not have the infrastructure to absorb the administrative demands of the application process (Bishop et al., 2014).

The credentialing process as briefly outlined above can be slow, burdensome, difficult navigate, and unsustainable for solo providers or small provider practices and groups that do not have adequate resources (such as time, staffing, or additional funding). Please refer to Table 5-3 for selected RFI quotes about provider experiences and perceptions with enrollment and credentialing for Medicaid, Medicare, and Marketplace plans:

TABLE 5-3

Selected RFI Quotes about Provider Experiences and Perceptions with Enrollment and Credentialing for Medicare, Medicaid, and Marketplace Plans.

Credentialing

To receive the accreditation that they need to conduct business and for legal liability reasons, payers must credential all health care providers in their network. A health care organization, third-party organization, or payer can complete the credentialing process, which involves assessing and verifying the education, training, registrations, licensing, certifications, and medical practice history of individual providers, including provider-related disciplinary actions and malpractice allegations. Even health care providers who have completed a credentialing process with another organization must request participation with each payer as a prerequisite to filing any claims. In general, each payer has its own health care provider enrollment process with requirements that often duplicate what the care provider supplied during the initial credentialing process. Payer enrollment includes negotiating the behavioral health care provider contract and other information the payer needs to process claims from that provider (Medallion, 2023). In addition, many plans require separate enrollment for behavioral health and other clinical services, creating additional burdens for providers that operate in an integrated practice, as network access is not granted simultaneously for behavioral health and medical services.

The credentialing and provider enrollment process is unavoidable and burdensome, especially for many behavioral health providers in independent practices who lack administrative support and staffing. Figure 5-3 depicts the credentialing workflow, showing the typical credentialing process to participate in Medicaid managed care.

FIGURE 5-3

Typical credentialing process to participate in Medicaid managed care.

Several credentialing burdens exist. First, it is estimated that the current credentialing process, which is sometimes manual and paper-based, contributes to substantial administrative waste (Health Affairs, 2022). For example, payers may use a paper-based data exchange that may take 90 to 180 days, and they must credential all new health care providers and repeat the process every 1 to 3 years after that (“recredentialing”). Rosters of credentialed providers must be updated and sent to individual payers monthly or quarterly, including specific practice locations. Health care providers are not typically informed if they are dropped from the credentialed list, which can occur because of a typo or minor data entry error. Instead, a care provider who is no longer credentialed may learn of his or her status when a subsequent claim for reimbursement is denied.

Second, payers may each have their own rules and processes for behavioral health care provider enrollment. Multiple credentialing processes for each payer are time consuming and expensive, as each process may involve multiple follow-up phone calls or emails, especially if there are errors or missing information in the original application. This lack of consistency—with different documentation requirements, processes, and timelines, results in significant complexity for behavioral health providers. Third, health care providers cannot submit a bill to a payer until they are enrolled with that payer, which translates into payment delays and potential financial hardship, especially for small practices or independent practitioners (Hansen et al., 2015; Mullangi et al., 2021). Finally, evidence suggests that care providers who accept insurance often contract with multiple plans, amplifying the complexity of credentialing and enrollment processes (CAQH, 2019). For example, while data on behavioral health providers is limited, one study from 2019 showed that the average primary care practice contracted with 12 managed care plans, and 12 percent of practices contracted with 20 or more plans (Ly and Glied, 2014).

Respondents to the committee’s RFI similarly identified credentialing as a challenge to participation, along with low reimbursement. Some respondents characterized the paperwork required to participate in programs, especially with Medicare and Medicaid, as “excessive.” Several respondents commented on a prolonged and cumbersome credentialing application process that could take several months for them to get admitted as in-network providers. If a care provider had a change of address, even relatively minor suite or street number revision, formal documentation had to be provided to make this request, during which time reimbursement would be held. Finally, respondents stated that the recredentialing process, which occurred as frequently as annually for some plans, was time consuming and cumbersome, particularly for Medicaid.

(W)e lifted certification requirements, allowing co-location in different places has been a key. . . . So then private practitioners don’t have to go out and open up their own clinics, (N)ow that we’ve really decreased that certification piece of this, the credentialing, as far as Medicaid enrollment, we want to make as easy as possible.

Paula Stone, webinar 3 panelist

Innovations to Improve Mental Health and Substance Use Disorder Access in Medicare, Medicaid, and Marketplace Insurance Plans

States have recognized credentialing processes as a challenge to behavioral health provider participation in Medicaid. Over half of states report moving to centralize or standardize credentialing for fee-for-service providers or requiring Medicaid managed care organizations to do so (Saunders et al., 2023a). Paula Stone, an Arkansas Medicaid administrator who spoke in webinar 3, reported a similar effort: “We’re looking at some programs that allow us to have a single platform where we can credential and then our . . . provider organizations . . . (will) not have to do . . . recredentialing with every different managed care organization.”

I would like to accept Medicaid for children in my state. The process of applying has been arduous and complicated. I got accepted for state Medicaid, however, most children in the state use an MCO after multiple confusing emails, attempting to get credentialed with the most common MCO Highmark, Blue Cross Blue Shield, I was told it will take over six months for them to consider my application. The process is too complex and burdensome. It takes too long and I understand why more providers in private practice do not take Medicaid. So many of the questions were things I had to Google in order to understand what they were asking. There should be a streamlined way to apply and get credentialed. The MCO explained the delay in that they don’t have enough people processing credentials. That means that they are using money they collect for other things, then to quickly get people through this process.

—RFI respondent, PhD./Psy.D.

Private practice, DE

Setting-Specific Administrative Barriers

Several RFI respondents shared a perception that the administrative burden from Medicare and Medicaid is lighter in academic and other hospital settings than in independent practice, the result of academic medical centers and hospitals having dedicated billing staff. However, respondents in academic settings frequently stated that administrative burden would deter them from accepting these public insurances in an independent practice environment. In fact, RFI respondents in academic medical centers and other hospitals who felt they could comment on insurance-related matters highlighted administrative burdens in their responses, including high demands for prior authorizations and credentialing timelines, as lengthy and inefficient. Behavioral health care providers noted concerns for vulnerable patient groups on public insurance programs and administrative burdens that can take precedence over patient care. As a licensed alcohol and drug counselor and licensed mental health practitioner noted, “The amount of paperwork and documentation required takes away from patient care time.”

Similar to the hospital-based care provider input received, behavioral health care providers working in community-based health entities typically reported that they relied on internal administrative staff to fulfill administrative tasks such as credentialing and billing. Such infrastructure seems to insulate the care team from the burdens associated with these administrative tasks. Table 5-4 shows additional selected quotes from RFI participants about their experiences working in Medicare, Medicaid, and Marketplace.

TABLE 5-4

Selected Quotes from the Committee’s RFI on Behavioral Health Workforce Experience by Setting.

OTHER BURDENS AND STRESS FACTORS THAT LEAD TO ATTRITION, BURNOUT, OR DISSATISFACTION

Additional burdens may affect care delivery processes daily, driving increased turnover and exacerbating behavioral health care provider participation shortages in public insurance programs (Figure 5-4). Evidence suggests that the combined allosteric load of these daily burdens contributes to cynicism, depersonalization, exhaustion, and ultimately, burnout and workforce attrition (Hallett et al., 2024). There is modest empirical evidence regarding the relative role these burdens play on behavioral health providers who serve enrollees in public or publicly subsidized insurance programs, particularly regarding their retention within the existing workforce. Contributing factors that elevate the daily burdens of delivering behavioral health services may include: the complexity of patient needs and the inability to meet these needs; fragmentation of data, data flows, and documentation burden; and additional workplace burdens (Counts, 2022; Satcher, 2000).

FIGURE 5-4

Factors affecting clinician well-being and resilience. SOURCE: Brigham et al., 2018.

INTEGRATING CARE TO IMPROVE BEHAVIORAL HEALTH CARE PROVIDER SATISFACTION

Providing care in integrated settings can reduce the challenges that care providers experience treating clients with complex conditions. Research has shown that integrating medical, mental health, and SUD treatment benefits patients, payers, and health care providers. Multiple studies have found that integrated behavioral health treatment reduces treatment times, improves patient outcomes, and is more cost-effective than segregated care for different conditions (Kroenke and Unützer, 2017). Other benefits include increased health care provider satisfaction, improved patient treatment plans, increased patient satisfaction, increased engagement and adherence to treatment plans, and reduced system barriers (Heath et al., 2013).

A broad spectrum of innovative behavioral health care models are evolving across the United States (Heath et al., 2013). Primary care is an entrance point for most patients, since 90 percent of patients with mental health disorders are seen in the medical sector (Kroenke and Unützer, 2017). Recent data show that the share of adult primary care visits addressing mental health concerns increased by over 50 percent between 2006–2007 and 2016–2018, underlining the importance of this health care provider group in providing behavioral health care (Rotenstein et al., 2023). Studies have shown that consultative models support medical practitioners and improve patient outcomes and that co-located models, in which a licensed behavioral health practitioner integrates into the core primary care team, improve the behavioral health provider experience by helping behavioral health providers care for more complex patients (Funderburk et al., 2012; Torrence et al., 2014), leading to higher provider satisfaction (Angantyr et al., 2015; Serrano and Monden, 2011; Torrence et al., 2014). Examples include the Primary Care Behavioral Health model, which has grown over the past two decades (Reiter et al., 2018), and the Patient-Centered Medical Home (PCMH) model, for which approximately 13,000 practices are recognized by the National Committee for Quality Assurance PCMH recognition model (NCQA, 2023).

The more team-based collaborative care model of treatment by behavioral health and medical professionals is distinguished by a behavioral health care manager serving as the bridge between professionals and the patient. There is strong evidence that the collaborative care model for mental health treatment is effective across multiple comorbid conditions, including pregnancy, neurology, oncology, chronic pain, diabetes, and other medical disorders among adolescents and older adults (Kroenke and Unützer, 2017; Reist et al., 2022).

A fully merged medical/behavioral health practice is the highest level of integration. Few of these exist, limiting evidence of their effectiveness (Heath et al., 2013). Developing integrated models is particularly challenging in rural areas, where behavioral health care providers are more limited. Vermont originally designed a hub-and-spokes model built on medical home payments to increase rural access to treatment for opioid use disorder. Hubs facilitated intensive outpatient care to stabilize patients; spokes were usually primary care practices that served as medical homes and provided office-based opioid treatment to patients, receiving consultative expertise and screening support from the hub. Other states followed Vermont’s lead and implemented hub-and-spokes models for MAT, with varying levels of success (Green et al., 2021). Similarly, the Veterans Administration is implementing a telehealth hub-and-spokes model for chronic pain treatment to augment services in rural and under-resourced areas by providing expertise and support to local practitioners. The hub-and-spokes model has promise for integrating care in rural areas through the use of teleservices aligned with local practitioners (Heath et al., 2013; Huffman et al., 2014; Katon et al., 2001; Kroenke and Unützer, 2017; Reist et al., 2022; Solberg et al., 2015; Unützer et al., 2001, 2020).

Despite the potential for increased behavioral health care provider satisfaction, significant savings, better patient outcomes, and improved access to services, effective integrated care remains the exception and not the norm in treatment. Integrating care across medical, mental health, and substance use treatment silos continues to face many obstacles, arising from decades of treating these three practice areas as distinct, separate, and unrelated forms of care. To integrate care so that the whole person is treated requires integrating or sharing information, a team approach to treatment plans and services, and financial payment models that adequately cover the complexity of integrated care. All must be addressed for integrated care to become the standard for treating a patient with comorbid behavioral health and medical conditions (Petts et al., 2022).

Real-world data suggest that average treatment response to integrated care for depression across a large sample of clinics was substantially lower than response rates reported in randomized clinical trials, with patient factors and clinic factors, including the level of collaborative care experience and implementation support, contributing heavily. Other research has shown that financial integration alone is less effective without clinical transformation efforts (Kroenke and Unützer, 2017).

Widespread adoption of integrated care lags far behind the evidence of its effectiveness. To incentivize the adoption of integrated care, reimbursement models should be designed to adequately compensate and incentivize collaborative care, but several barriers make this difficult:

• Current payment systems are structured to separate behavioral health and medical treatment rather than compensate for team-based care.
• Bundled payments, such as for pregnancy, preclude additional reimbursement for behavioral health comorbidities.
• Differing reimbursement structures among commercial, Medicare, and Medicaid create a barrier to implementing collaborative care across all comorbid patients in a practice.
• EHR limitations in many behavioral health practices, particularly smaller practices, make it difficult to join a collaborative care arrangement.

Addressing these barriers requires:

• Care management and coordination between medical and behavioral health treatment must be included in compensation.
• Additional time for collaboration and team-based communication/planning is needed.
• Reimbursement and accountable care organization payments should be designed to recognize all team members in a collaborative care arrangement.
• Technical assistance is needed for smooth practice transformation to implement collaborative care.

These challenges are evident in the recent Kaiser Family Foundation survey of actions that states are taking to support the behavioral health workforce. While the majority of states reported addressing reimbursement, prompt payment, credentialing and prior authorization challenges, only a few indicated they were putting in place incentives to drive integrated care (Saunders et al., 2023a).

Finding: Evidence suggests that several clinical program models (including integrated and collaborative care arrangements) can help to ameliorate the day-to-day behavioral health provider workplace burdens, fostering provider satisfaction and more optimal patient care.

Conclusion 5-6: A key barrier for behavioral health provider retention and satisfaction in Medicaid and Medicare, in particular, is the inability to meet patient needs, driven in part by the complexity and fragmentation of the care delivery system and patient navigation challenges. While building behavioral provider participation in Medicare, Medicaid, and Marketplace programs is important, it is not sufficient to ensure that patients are matched to the right behavioral health providers according to their clinical, cultural and language needs, at the right time and right place.

CONCLUSIONS

Conclusion 5-1: Insufficient and often unstable reimbursement has been identified as a key factor driving low care provider participation in public insurance programs. Low reimbursement is particularly stark when compared to the higher out-of-network rates paid in commercial insurance markets and higher cash-pay rates. Across payers, there is often a lack of transparency on how rates for behavioral health services are currently set, with consistent undervaluation of work efforts for behavioral health care providers and inadequate accounting for the costs of care provision.

Conclusion 5-2: There is limited and mixed evidence about the effects of reimbursement rate increases on care provider participation in insurance programs, and existing evidence is lacking on the magnitude and scope of reimbursement required to increase access to behavioral health providers in Medicaid and Medicare. Recent state efforts to modify behavioral health payments, particularly in Medicaid, should be evaluated and monitored closely.

Conclusion 5-3: Evidence suggests that the behavioral health rates for care providers, particularly for the Medicaid and Medicare Advantage plans, have been inadequate to attract and retain behavioral providers in the plan’s networks. In addition, rates do not have parity for the same services with other behavioral health providers. Furthermore, the evidence suggests that because of billing codes, there is a lack of parity between services for substance use disorder and mental health conditions. As a result, the rationale for the existing reimbursement structures must be re-evaluated, revised, and subsequently and regularly updated to reflect the full cost of care, including ancillary service provision, administrative requirements, and parity among care providers.

Conclusion 5-4: Evidence suggests that administrative burdens, particularly concerning delayed and denied payments, audits and the real and perceived threat of clawbacks, are at least as important as inadequate rates in disincentivizing behavioral health providers from participating in Medicaid and that similar disincentives exist in Medicare Advantage where inappropriate payment denials have been demonstrated. Given that behavioral health providers are more likely to practice independently and lack administrative support, efforts are needed to simplify and streamline administrative processes including credentialing, billing, and claims processes.

Conclusion 5-5: Research, regulatory actions, and reported behavioral health provider experience provide compelling evidence that current prior authorization activities demand reform. The time, expense, and patient care delays associated with insurer-applied usage management tools factor into behavioral health provider participation decisions and decrease care access for patients. Policies recently adopted by some states, CMS, and the broad-based participants in the “Consensus Statement” (referred to above) provide guidance for reform.

Conclusion 5-6: A key barrier for behavioral health provider retention and satisfaction in Medicaid and Medicare, in particular, is the inability to meet patient needs, driven in part by the complexity and fragmentation of the care delivery system and patient navigation challenges. While building behavioral health provider participation in Medicare, Medicaid, and Marketplace programs is important, it is not sufficient to ensure that patients are matched to the right health care providers according to their clinical, cultural and language needs, at the right time and right place.

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