Differential Reimbursement of Psychiatric Services by Psychiatrists and Other Medical Providers
Mark, T. L., Olesiuk, W., Ali, M. M., Sherman, L. J., Mutter, R., & Teich, J. L. (2017). Differential Reimbursement of Psychiatric Services by Psychiatrists and Other Medical Providers. Psychiatric Services, appips201700271. DOI: 10.1176/appi.ps.201700271
OBJECTIVE: Given low psychiatrist participation in insurance networks, this study examines how psychiatrists are reimbursed in network and out of network under commercial insurance relative to other providers for the same diagnoses and services.
METHODS: Paid private insurance claims from the 2014 Truven Health Analytics MarketScan Commercial Claims and Encounters Database were analyzed. The sample included all services billed for 3.8 million individuals with a mental disorder as the primary diagnosis by psychiatrists, nonpsychiatrist medical doctors, psychologists, social workers, or psychiatric nurses. The authors determined the most common services provided by each provider type, the median reimbursement and median out-of-pocket payment for the services by provider type and by network status (in or out of network), and the proportion of bills for services delivered out of network.
RESULTS: "Evaluation and management" services for presenting problems of low to moderate and moderate to high severity were the two procedures most frequently billed by psychiatrists and nonpsychiatrist medical doctors. The median reimbursement for services for presenting problems of low to moderate and moderate to high severity was 13% less ($66 versus $76) and 20% less ($91 versus $114), respectively, for psychiatrists versus nonpsychiatrist medical doctors if the services were provided in network but 28% higher ($100 versus $78) and 6% higher ($122 versus $115), respectively, for psychiatrists versus nonpsychiatrist medical doctors for services provided out of network.
CONCLUSIONS: Psychiatrists receive lower in-network reimbursement than nonpsychiatrist medical doctors for many of the same services. This may contribute to psychiatrists' lower participation in insurance networks relative to other providers and has implications for patient cost sharing and access to psychiatrists.