Esther N. Schwartz and David R. M. Trotter
Department of Family and Community Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
Psychologists and other behavioral health providers (BHPs) have become increasingly integrated into primary care in the United States (Bray, 2016; McDaniel et al. 2014; Miller, Petterson, Burke, Philips, & Green, 2014). The types of administrative issues encountered by BHPs working in primary care will vary by proximity of BHP and medical services locations and the level of integration between medical and behavioral health services. BHPs face administrative challenges that are distinct from providers in traditional mental health settings. In this article, the practicalities of BHPs' daily function such as their appointment structure, coding and billing for services, documentation, availability of administrative support, and position in the organizational hierarchy are discussed. Additionally, BHPs' navigation and resolution of ethical quandaries specific to psychological practice in a medical setting are also explored.
Primary medical care (PC) is defined as “the provision of integrated accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (Institute of Medicine, 1994, p. 1). PC clinics, including family medicine, general internal medicine, and general pediatrics practices, are the primary entry point for medical and mental healthcare for most Americans. Specifically, more than half (54.6%) of all healthcare visits occur with a primary care physician (PCP) (Centers for Disease Control [CDC], 2012). Integration of BHPs into PC is important as psychosocial and behavioral factors such as diet, activity level, and substance use critically affect morbidity and mortality in the United States. Additionally, psychological symptoms and disorders are frequently comorbid with medical illnesses (Petterson et al., 2008). Finally, approximately 50–70% of Americans who receive treatment for mental and behavioral health and substance use problems do so from PC (McDaniel & deGruy, 2014). There is mounting evidence supporting that the integration of PC and behavioral health improves health at individual and population levels (Blount et al., 2007). However, primary care behavioral health integration is still not yet widespread.
The types of administrative issues encountered by BHPs working in PC will vary at least partially as a function of the level of integration between medical and behavioral health services. In general, integration of services requires a team‐based collaboration between all providers using a biopsychosocial framework (Bray, 2016; Engel, 1977). There are three broad levels of integration: coordinated, colocated, and fully integrated care (Bray, 2016). In coordinated care, the BHP retains a separate practice (i.e., separate physical spaces, electronic health record [EHR] systems, scheduling and billing staff) and collaborates via referrals from the PCP. In a colocated arrangement, the psychologist and PCP are located within the same office space but maintain separate practices (e.g., scheduling and billing staff, EHR) and financial arrangements (e.g., billing and reimbursement structures). In this arrangement the BHP accepts referrals from PCP and provides consultation (written and face to face). In a fully integrated model, the psychologist is embedded within the primary care system and is an integral part of care delivery and treatment. They share the same space, systems (e.g., EHR), and resources (e.g., scheduling and billing staff). In these settings, psychologists may provide immediate consults to patients during their doctor's visits as requested by the PCP, as well as see patients for brief interventions. For a full discussion of levels of integration, the reader should see Bray (2016). Deft negotiation of administrative issues requires an awareness of the administrative processes operating in each clinical setting and the level of behavioral health service integration.
BHPs working in colocated or fully integrated primary care settings typically work in a medical facility. Familiarity with the organizational hierarchy and the numerous players in the medical system is helpful for ensuring coordinated care. Key players in these facilities often include a medical director (a physician who makes decisions on standing orders, supervises “mid‐levels,” and may provide general oversight of medical services), medical staff (e.g., physicians and mid‐level providers like nurse practitioners and physicians assistants), clinic manager (a staff administrator who oversees the day‐to‐day operations of the clinic and provides general supervision of the staff), various department managers (e.g., nurse manager, billing manager, medical records manager, scheduler/call center manager, lab manager; typically report to the clinic manager), care coordinators (may coordinate referrals and/or manage patient care plans), and various departmental staff (e.g., nurses, billers/coders, call center staff). It is critical that a BHP understands where they fit into this hierarchy, including who they report to, who provides practice oversight, how they interact with the other key players, and what services and support they will receive from the various clinic departments (e.g., scheduling assistance, billing/coding). For example, will the BHP report to the medical director and be granted privileges in accordance to their license/certification and in a manner similar to the other providers, or will they report to the clinic manager, be considered general staff, and be afforded fewer privileges? Discussions regarding how a BHP will fit into the administrative clinic structure is critical prior to integration.
As stated above, BHPs should consider and negotiate how they will interact with, and what services they will receive, from the various clinic departments. For example, who will take charge of the day‐to‐day management of the BHPs schedule? Is the BHP responsible for scheduling of patients, taking their phone calls, and contacting them if they have not showed up, or does the scheduling department complete these tasks as they do for the medical providers? In full integration, the BHP's appointments are often marked on the same standardized weekly clinic grids utilized by all other providers. With these grids in place, the BHP's current appointments and total available slots in the future are visible to the entire clinic, increasing transparency and availability for same day access (Kearney, Smith, & Pomerantz, 2015). An additional question is, who does the BHP's billing and coding? Does this responsibility fall under the purview of the BHP's responsibilities, or is this handled by the billing/coding department in accordance with the other providers? It is advisable (when possible) for patients to have a generally equivalent experience (e.g., with scheduling, billing) with the clinic regardless of the type of services (i.e., medical or behavioral health) they are receiving.
Space in PC settings is often at a premium, and clinics are typically not designed with behavioral health practice in mind. Often, the only available space to see patients is an exam room, and BHPs may be expected to meet with patients in exam rooms. Additionally, it is the norm for many PC practices that providers do not have a private office space for charting and completing other administrative activities (e.g., letter writing, responding to patient messages) and may instead do these activities in a more central provider pod or work hub. While this may take some adjustment on the BHP's part, these centralized work spaces encourage communication between providers in ways that enhance coordination, builds camaraderie, and conveys accessibility. Even if a psychologist is designated a private office space to see patients, simply leaving the door open and being visible conveys accessibility (Robinson & Reiter, 2016). It is advisable that BHPs advocate for space that is roughly equivalent to that or their medical colleagues, use space judiciously, and be flexible.
Physician visits are typically scheduled in 15‐min increments (high volume), while traditional mental health visits are typically scheduled for 50 min (comparatively low volume). When BHCs work in a coordinated model, they often retain this 50‐min structure. However, when working in colocated or fully integrated settings, many move to using a 25‐min session structure (a higher volume 16 total appointment slots in a day). When choosing an appointment structure (i.e., either 50 or 25 min), a number of administrative issues should be considered. First, what are the clinical volume expectations in the clinic? Do the other providers expect you to have a volume more similar to theirs, or is there no expectation of this? If a BHC works in a clinic with many other providers, a 25‐min structure is generally preferable as it allows the professional to be available for more of the PCP patients. Second, what level of staffing is available for patient scheduling and check‐in/check‐out? Are there enough scheduling staff to accommodate an additional 16 patients a day plus the calls they will generate? Finally, will the BHP utilize nursing staff to room patients? While this is not common, some clinical settings will provide nursing support for their BHP to room patients, allowing them to move faster through their clinic without having to make trips to the waiting room or ensure that patients have completed the appropriate paperwork. For a more comprehensive discussion and justification for the use of 25‐min appointment structure, the reader may consult Robinson and Reiter (2016).
Psychologists' documentation of patient encounters is an important administrative skill, but the style and processes of documentation differ based on level of BHC integration. In a coordinated model, BHP documentation will look similar to other mental health settings, with the addition of workflows and processes to ensure that the referring PCP is provided some level of feedback on the referral (e.g., that the patient was seen, that progress is being made). BHPs working in colocated models often document in a manner similar to traditional mental health providers (i.e., in a separate system, using traditional mental health note structures), while some document more like a BHP in a fully integrated setting. BHPs in fully integrated settings typically document in the same chart used by the PCP. This kind of communication requires that notes are written in a way that is useful to other healthcare team members. Typically, this means that the notes use a structure similar to other providers (e.g., SOAP style), are concise, do not contain psychological jargon, clearly convey the assessment of the patient including risk factors, include a follow‐up plan, and provide recommendations for other providers (when necessary). When using this style of documentation, BHPs need to discuss the strengths and limitations of a shared health record during the informed consent discussion with the patient. The psychologist should also clarify with the patient what session information will be shared in the chart.
When using a shared chart, BHPs need to also consider who should have access to their notes. A PCP's notes are typically available to all staff and other providers, including other physicians and mid‐levels, nursing staff, scheduling/call center staff, billers/coders, and other general administrative staff. A BHP using a shared EHR should carefully consider which of these groups will have a legitimate need to access to their portion record. For example, it would be important for the BHP to grant access to all referring providers in the clinic, as they will be collaborating on patients. Additionally, it may be important for some of the nursing staff to have access to these notes, as the nursing staff are often in charge of triaging patients who contact the clinic. However, it may not be necessary for scheduling staff and general administrative staff to have access to the notes. The BHP should give careful consideration to this issues and inform patients as to who will have access to their record.
In a coordinated practice, a BHP will receive referrals from a PCP's office, as well as from other sources. However, in colocated and fully integrated clinics, PCPs may be a BHP's sole source of referrals. Ensuring that the referral process is easy, smooth, and rapid is critical in promoting PCPs' actual placement of the referral and will increase the likelihood that a patient will follow through with the initial appointment. BHPs should consider the process of placing written and in‐person referrals. PCPs will be most familiar with creating written referrals, as they refer patients to a host of services (e.g., preventive care screenings, specialist referrals). As most PC practices use an EHR, BHPs should work closely with their IT departments to ensure that their electronic referral process closely matches those that PCPs use for other services. Additionally, BHPs should ensure that common referral barriers (e.g., requirement of prior authorization for service, delays, wait lists) are removed or managed. While PCPs will be most familiar with written referral processes, in‐person referrals are one of the BHPs most effective tools for achieving coordinated care. The most effective in‐person referral is the “warm hand‐off.” A warm hand‐off is when a PCP consults the BHP in person and then asks the BHP to meet a patient during the patient's regularly schedule PCP visit. Warm hand‐offs by the PCPs to BHPs may be completed in just a few minutes and demonstrably increase the likelihood a patient will initiate therapy. In‐person referrals may also occur during a “curbside consultation.” A curbside consult is a brief discussion between a BHP and a PCP about a clinical issue that occurs spontaneously. These can occur in an exam room, PCP common work space, or hallway (being mindful of confidentiality issues). Curbside consults are good opportunities to provide accurate, specific, and actionable information on a behavioral problem and support the providers to be more effective in their interactions with patients. Over time, repeated consultations may provide physicians with a good sense of the biopsychosocial model in action and the range of services a psychologist provides. No less important, collaboration communicates to the PCP that they have a potential ally in caring for their patients (Gunn & Blount, 2009). Regardless of how a referral is placed, once a BHP has completed the initial referral visit, he or she should provide the referring PCP with feedback about what the patient is targeting in treatment and how treatment is progressing as a way to close the referral loop.
BHPs working in either coordinated or colocated systems typically bill and are reimbursed in ways similar to that of traditional mental health settings. However, billing issues continue to be a serious hurdle in integrated primary care practices (Robinson & Reiter, 2016). Clinic administrators may hire a BHP with no plans for that provider to bring in direct revenue. In this model, the BHP is typically salaried hourly and paid as a member of the team. This system can work well in capitated payment structures, like those found in accountable care organizations (ACO). A capitated payment structure is a reimbursement model in which a health system receives a yearly flat fee from an insurance carrier to provide all services for a patient. Further, insurers may offer additional monetary incentives if the system can reduce overall healthcare costs for its patients by improving quality of care delivered (e.g., decreasing ER visits and hospital stays, reducing redundancy and waste). In fact, there is some evidence to suggest BHPs can reduce healthcare costs at a system level, making their inclusion in these systems attractive. See Blount et al. (2007) for a review of increased cost‐effectiveness when behavioral health services are integrated into primary care.
Most BHPs still work in traditional fee‐for‐services models. BHPs working in these environments are typically either employees of the system who receive payment based on their billing or are contractors who provide services for a contracted fee. In fee‐for‐services systems, BHPs bill using current procedural terminology codes (CPT) to bill for services. There are two categories of CPT codes available to BHPs: psychotherapy CPT codes (e.g., 90791) and health and behavior CPT codes (i.e., 96150–96155). The psychotherapy codes are used for billing when a BHP is seeing a patient for a mental health issue (e.g., depressive disorder, anxiety disorder). Available psychotherapy CPT codes include those used for testing and assessment and counseling (based on time; 30, 45, 60 min). The CPT codes are used by those working in traditional mental health settings as well as all levels of PCBH integration. Health and behavior codes allow BHPs to bill for services that address social and behavioral aspects of physical health problems as diagnosed by a medical professional (Robinson & Reiter, 2016). Therefore, a BHP can bill for services to improve the course or outcome of medical issues like obesity, chronic pain, and diabetes. It is important to note that billing for both health and behavior codes and mental health codes in the same encounter is not allowed.
Protecting patient confidentiality and privacy in the primary care setting is an important administrative issue but can be challenging. Physicians and BHPs have different laws, rules, and ethics codes that govern provider–patient confidentiality. For example, medical care is organized around referrals and informal consultation with others in which protected health information is exchanged. This is permissible under the Health Insurance Portability and Accountability Act (HIPAA), which allows HIPAA‐covered healthcare providers to disclose protective health information with another healthcare provider without the patients written consent, if the exchange of information pertains to that provider's treatment of the patient (see Federal Regulation 45 CFR 164.506). As such, PCPs expect team members to be able to discuss all patient care issues as deemed necessary. However, BHPs may be limited in their ability collaborate in this way as they are not covered under HIPAA and are subject to other privacy and ethical considerations. For example, the American Psychological Association Ethical Standard 4.06 clearly states that when consulting with colleagues, psychologists “do not disclose confidential information that reasonably could lead to the identification of a client/patient.” Therefore, a curbside consult between a PCP and a psychologist BHP in which a patient is referred to by name and medical problem may be permissible under HIPAA, but in violation of APA standards on confidentiality. However, in the primary care culture of openly sharing patient information as a way to coordinate care, a psychologist's reticence to collaborate may be counterproductive (Gunn & Blount, 2009). BHPs must learn to navigate the complex rules, regulations, and work expectations regarding confidentiality. One of the simplest administrative solutions to this issue is to notify patients in writing during the informed consent process that the BHP may collaborate with other providers in the service of their care. Further, during informed consent, patients can be informed about how their written record will be handled (see above).
Medical providers and BHPs may possess different perspectives on the issue of multiple relationships. For example, consider the example of a provider providing and/or receiving clinical services to/from another colleague or trainee. The APA Ethical Code states: “A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists” (see Standard 3.05 in the “Ethical Principles of Psychologists and Code of Conduct”; American Psychological Association [APA], 2017). While APA's code does not explicitly forbid treating colleagues or professionals in training under this code, the onus would fall on the psychologist to prove that entering into such a relationship would be reasonable, which would be difficult to do. On the other hand, the American Medical Association's (AMA) Code of Ethics stipulates that while one should exercise caution (for issues similar to those raised by the APA), “car[ing] for a fellow physician is a privilege” and that “physicians‐in‐training should not be required to provide medical care to fellow trainees, faculty members, or attending physicians if they are reluctant to do so.” Taking these guidelines in combination in a real‐world setting, BHPs and PCPs may have very different opinions about the appropriateness of working with a patient with whom both providers have multiple relationship (e.g., colleagues, family members, relatives of current patients). Managing multiple relationships as a BHP is an important administrative consideration, as it will influence the referrals (and associated referral process) that a BHP will or will not accept. Here we will discuss the two types of multiple relationships BHPs will most often encounter and potential administrative solutions.
Psychologists are trained communicators with expertise in emotions, relationships, and behavior. They are in an apt position to promote team development and a healthy culture in the workplace (McDaniel & Fogarty, 2009). In primary care, the psychologist may be called on to help staff deal with difficult and divisive patients, identify staff burnout, and improve workflows (McDaniel & deGruy, 2014). In some situations, clinic staff may ask the psychologist for help with a personal problem. In such scenarios, a BHP must adopt a policy(s) that will help them navigate these requests. These policies are likely to fall on a spectrum, ranging from a refusal to see any colleagues as patients to a policy in which the BHP will see anyone for an initial appointment. If a BHP adopts a policy refusing to see colleagues as patients, this is best communicated in the beginning when negotiating the terms of a practice. It is always easier to adopt this policy from the beginning, rather than attempt to implement it later on. This policy should then be clearly communicated to providers and staff. If a BHP adopts a policy on the other end of the spectrum, prior to intervening, it is recommended that the psychologist consider his or her working relationship with the staff member, the severity and sensitivity of the problem, and the likelihood the consultation will negatively impact the working relationship between staff member and BHP and the team (Reiter & Runyan, 2013). Again, if a BHP choses such a policy, this should be communicated to providers and staff in a clear format. Regardless of the policies guiding a BHP's practice, in the event of crises or problems with elevated risk to the staff member, the BHP may advise follow‐up care such as counseling or hospitalization. Additionally, all services rendered to colleagues should be documented in their chart in a fashion similar to documenting other patients' information.
Issues of multiple relationships are also common when working with non‐colleague patients. In primary care, it is not uncommon for members of the same family to receive care in the same clinic and even from the same provider (“whole family care”). PCPs may be skilled at navigating the challenges inherent in these multiple relationships, but such scenarios are far less common in specialty mental health settings and may present ethical and administrative challenges to psychologists (Reiter & Runyan, 2013). Consider the plausible example of an elderly man referred to a BHP to address suicidal ideation and his adult daughter who is referred to the same BHP for a distinct but related issue, stress‐induced gastritis. In this scenario, if the BHP were to follow the APA Standard 10.02 Therapy Involving Couples of Families stating “When psychologists agree to provide services to several persons who have a relationship (such as spouses, significant others, or parents and children), they take reasonable steps to clarify at the outset (1) which of the individuals are clients/patients and (2) relationship the psychologist will have with each person,” then the BHP would risk violating APA Standard 4.01 Maintaining Confidentiality, which instructs psychologists to “take precautions to protect confidential information.” “Whole family care” presents an ethical dilemma for the BHP as it is impossible to abide by one of these guidelines without violating the other (Reiter & Runyan, 2013). In this case, the BHP may not even be aware that father and daughter are related when they are referred. In the event that the BHP is made aware of this existing relationship, several different administrative actions can be taken. First, if other BHPs are available at the clinic, it would be advisable to refer one of the family members to see another BHP. If there is only one BHP, then they should assess the extent to which the father's presenting issue and the daughter's presenting issue are reasonably discrete and can each be conceptualized and treated without undue consideration of the other. Based on this assessment, the BHP will have to prioritize which standard will take precedence and be prepared to provide a rationale for this decision.
Thus, even when embedded within the primary care team, psychologists' administrative challenges are unique from medical providers. Moreover, primary care psychologists' practice management, reimbursement process, and understanding of confidentiality and multiple relationships differ from their colleagues working in traditional mental health settings.
Esther N. Schwartz, PhD is a postdoctoral fellow in primary care psychology in the Department of Family and Community Medicine at the Texas Tech University Health Sciences Center. Dr. Schwartz received her PhD in counseling psychology from the Department of Psychological Sciences at Texas Tech University and completed an APA‐accredited predoctoral internship in psychology at the Dallas VA Medical Center.
David R. M. Trotter, PhD is assistant professor and director of behavioral sciences in the Departments of Family and Community Medicine and Medical Education at the Texas Tech University Health Sciences Center. Dr. Trotter earned his PhD in clinical psychology at Texas Tech University and received postdoctoral training in primary care psychology at the UMass Medical School, Center for Integrated Primary Care (Department of Family Medicine). His areas of expertise include behavioral medicine, primary care behavioral health integration, and medical education.