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How to Build Better Relationships with the Health Insurance & Payer Communities

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Dr. Jessica Badichek, Chief Informatics and Compliance Officer, MediTelecare

Modern healthcare is a complicated dance between quality and quantity.

Payers and insurance providers want better patient outcomes due to the high cost of ill health, while health providers want to ensure that their patients are not overlooked and are properly cared for.

To understand how we can meet the needs of both patients and payers, we will need to take a step back and look at the relationship between payer communities and telehealth services.

Behavioral Telehealth is here to stay

The concept of telehealth has been around for a while, but it didn’t become the mainstay we know today until the pandemic. Before “6 feet apart,” few insurance companies recognized the importance or necessity of virtual care. So even if the argument seemed convincing, it was too bold. Now, if you were to ask behavioral health individuals how they view providers, they would most likely mention telehealth as an option.

In other words, telehealth is here to stay. However, a few hurdles need to be addressed to ensure that quality care is provided to patients while cutting medical expenses for insurance companies.

One important component of quality health care includes the balance between quality versus quantity. Telehealth providers must see a number of patients daily, but with the increasing number of patients, quality measures must be put in place to ensure that each patient receives the best care.

For example, it is sometimes challenging to quantify behavioral health outcomes. However, with quality operating procedures in place, you can ensure that each patient receives broader, comprehensive care that reduces the use of medications such as antipsychotics and benzodiazepines. High-risk psychotropic medications pose the greatest threat and can lead to more negative outcomes, ultimately resulting in higher costs for the insurance provider and payer community.

Is Behavioral Telehealth Really Worth It?

Telehealth has many advantages; for one, it exponentially reduces costs for patients, families, facilities and insurance companies. For the patients, it allows them to see both general and specialized clinicians without leaving their homes. To see that remote specialists reduce on-site gas, time and staff costs and open up patients to specialized care nationwide.

Telehealth not only helps to reduce costs, but it also lends itself to seeing more patients more often. Regular virtual medical triage significantly reduces the likelihood that patients will be sent to the hospital, which is often costly to insurance providers. In addition, it expands the reach of care with trained providers and can appropriately diagnose behavioral issues and treat individuals with mental health conditions using a patient-centered approach using clinical protocols.

Older adults and individuals with behavioral health issues may experience a higher rate of mental health conditions and behaviors, including mood disorders such as depression or bipolar disorder, anxiety disorders, post-traumatic stress disorder (PTSD), and psychotic disorders. However, these patients are often misdiagnosed with a mental health condition due to incorrect symptoms and behaviour. These misdiagnoses can lead to inappropriate medication use, such as over-prescribing high-risk antipsychotics. Frequent visits to behavioral health patients via telehealth ensures that patients are treated with appropriate and safer medications, while also expanding the bottom line of each facility.

The health care system also suffers from provider and care shortages, so it’s no wonder that more digital tools and teletechnology services are being employed to expand reach and deliver care to underserved groups.

So, is telehealth worth it? Delivering accessible, patient-centered, high-quality virtual care is the perfect solution for patients, their families, their facility and their insurance provider. As a result, payers welcome telehealth and related practices as they benefit patients by increasing access to care, managing misdiagnoses, and reducing insurance costs by avoiding further unnecessary health complications.

Normal does not always mean optimal.

In most situations where telehealth is used, patients visit their clinician/specialist, the clinician writes the clinical notes that activate a billing code, and the insurer covers the cost. Although effective, there are still disadvantages. Quality is left to the clinician and the clinician alone. Nothing else protects the patient’s care.

Telehealth clinicians can often be sent to see patients with little to no support, producing costly and sometimes dangerous health outcomes. However, measures can be taken to ensure that patients receive specialized quality care. The implementation of quality operating procedures in telehealth practices ensures that clinicians are supported and well equipped to undertake individual behavioral health care.

It begins by hand-picking clinicians during hire/onboarding and continues through a credentialing process that ends with strict internal approval. To provide the best care, clinicians must be supported, trained and offered continuing education.

With quality standard operating procedures, insurance providers don’t have to worry about the quality of each patient’s care or whether the patients will be sent to the hospital due to misdiagnosis or unsafe medication use.

Policies and procedures Front and center

How can you implement structures to ensure standardised, quality and accessible telehealth services? First, let’s talk about URAC accreditation. URAC is an organization responsible for developing quality standards for the entire healthcare industry. The accreditation process is used to set high standards for a healthcare organization’s systems, procedures and techniques that the organization must meet on its own.

Payers and insurance providers typically seek partnerships with organizations with URAC accreditation, as it is synonymous with quality care. It provides a mark of distinction for healthcare and demonstrates the company’s commitment to quality, which means improved patient health outcomes. The financial benefits of accreditation are also twofold: Increased patient volume leads to increased revenue, and Medicare payments to accredited facilities are maintained as a result of appropriate patient status posting.

While having URAC accreditation is essential, facilities can also continually review and implement policies and procedures that ensure practices are within the bounds of laws and regulations. Procedures reinforce quality standards. For example, behavioral health patient screenings are a common practice that can be used to analyze and monitor patients. In addition, telehealth services help care facilities manage and monitor patients who often have large amounts of polypharmacy, where a patient may be taking more than one medication.

Screenings and patient analysis are often an afterthought, but they are a good indicator of how well a patient is adapting to medications, therapies and other forms of intervention.

Behavioral Telehealth Cuts Costs

Although virtual health care has grown significantly in recent years, the payer community and insurance providers have yet to take full advantage of its benefits. Benefiting from trained providers who can appropriately diagnose and treat behavioral issues through a patient-centered approach using defined clinical protocols lends itself to healthy patients. This ensures that patients are treated with appropriate and safe medications and even non-pharmacological options where possible, reducing the risk of adverse outcomes such as hospitalizations and medication side effects.

Telehealth is a good place to start as the payer communities and insurance providers seek to work with large numbers of patients while also practicing quality care techniques. By enabling proactive/regular clinical visits, taking steps toward URAC accreditation, and implementing quality procedures and policies using telehealth, the financial burden on payers and insurance providers in the healthcare system is drastically reduced.

About Dr. Jessica Badichek, PharmD, BCGP

Dr. Badichek completed her undergraduate studies at Fairfield University in Connecticut and her doctorate in pharmacy at the University of the Sciences in Philadelphia. She is currently the Chief Informatics and Compliance Officer at MediTelecare. She previously worked at ComprecareRx Pharmacy (PursueCare) working with opioid use disorder patients and Arrow/Partners Long Term Care Pharmacy working with hospice and senior patients. She has considerable experience and knowledge in all aspects of psychopharmacology and the use of psychotropic drugs in geriatric populations.

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