June 8, 2022
Attached and excerpted below please find an issue brief from the Mental Health Treatment and Research Institute (MHTRI) entitled “Federal Parity Law (MHPAEA): Non Quantitative Treatment Limitation of In-Network Reimbursement Rates: Non-Comparable Use of Factors of Provider Leverage a/k/a Bargaining Power and Workforce Shortages“.
This Issue Brief analyzes how some plans define and use the factor of “provider leverage” a/k/a “bargaining power” in different and inconsistent manners in setting network reimbursement rates for Medical / Surgical (M/S) providers as compared to MH/SUD providers – and how and why the non-comparable use of this factor is non-compliant with the Mental Health Parity and Addiction Equity Act (MHPAEA).
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Key quotes from the issue brief include:
- “The ability to refuse low reimbursements exemplifies provider leverage (bargaining power).
- “To comply with MHPAEA, plans and issuers must take measures that are comparable to and no more stringent than those applied to medical/surgical providers to help ensure an adequate network of MH/SUD providers.” DOL Self-Compliance Tool.
- “As reported by Kaiser Family Foundation…national data as of Sept. 30, 2021 shows more shortages for PCPs than for mental health providers (7447 vs. 5930 shortage areas).”
- “Nationally, the average in-network reimbursement for primary care professional office visits from commercial insurers was approximately 20% above Medicare reimbursement, and Out Of Network (OON) use of such visits was approximately 3% (i.e., 3% of all claims were paid to OON providers).”
- “So, even though there is an overall shortage of primary care providers in our country, within insurer networks there was no evidence of a shortage.”
- “Nationally, the average in-network reimbursement for MH/SUD professional office visits from commercial insurers was approximately 2.5% below Medicare reimbursement, and OON use of such visits was approximately 17%, i.e., 5.4 times higher than for primary care providers. In several states, this disparity was 10 times higher. For adolescents nationally, OON use of adolescent MH/SUD providers was 10 times higher than for pediatric providers.”
- “The fact that some plans define and utilize the factor of provider leverage a/k/a bargaining power differently for M/S as compared to MH/SUD providers, leading to opposite approaches to in-network reimbursement rates, results in a non-comparable and more stringent reimbursement methodology and rates for MH/SUD providers.”