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Managed Care and Parity Issue Brief - "Federal Parity Law (MHPAEA): NQTL of In-Network Reimbursement Rates: Non-Comparable Use of Factors of Provider Leverage a/k/a Bargaining Power and Workforce Shortages" - 6/8/22

  • 1.  Managed Care and Parity Issue Brief - "Federal Parity Law (MHPAEA): NQTL of In-Network Reimbursement Rates: Non-Comparable Use of Factors of Provider Leverage a/k/a Bargaining Power and Workforce Shortages" - 6/8/22

    National Council Staff
    Posted 06-08-2022 16:32
      |   view attached
    Dear Association Executives - Attached and excerpted below please find an issue brief from the Mental Health Treatment and Research Institute 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 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)."

    Please feel free to share this with your members. Please let us know if you have any questions. 

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    Key quotes from the issue brief include: 

     

    1. "The ability to refuse low reimbursements exemplifies provider leverage (bargaining power).

     

    1. "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. 

     

    1. "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)." 

     

    1. "Nationally, the average in-network reimbursement for primary care professional office visits from commercial insurers was approximately 20% above Medicare reimbursement, and OON use of such visits was approximately 3% (i.e., 3% of all claims were paid to OON providers)."

     

    1. "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."

     

    1. "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."

     

    1. "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."


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    Chuck Ingoglia
    President & CEO
    National Council for Mental Wellbeing
    Direct: (202) 684-3749


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    Neal Comstock
    Director of Membership
    National Council
    NealC@TheNationalCouncil.org
    202 748-8793
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