Running a behavioral health practice is demanding, and understanding 2025 behavioral health billing changes might feel like another burden. The last thing you need is to be tangled up in confusing billing rules when your focus is on your patients, your team, and providing vital care. But, like it or not, billing changes are a constant in healthcare. As we look towards 2025, there are some potential shifts on the horizon that could affect how you bill, get paid, and even how you structure your day-to-day work.
Navigating 2025 Behavioral Health Billing Changes
1. 2025 Behavioral Health Billing Changes & Telehealth
Many practices are successfully billing for telehealth services using specific codes and modifiers that were largely put in place during the public health emergency. But the big question for 2025 is: Will these current rules stick around, or will things shift again? Let’s break down what you need to watch for and what it could mean for your practice:
The Question of Permanency
For the past few years, temporary rules have made telehealth billing much easier. You’ve likely been using modifiers like GT or 95 to indicate telehealth services and selecting Place of Service codes that reflect the patient’s location, not necessarily your office. The key uncertainty is whether these flexibilities will become permanent. If they don’t, we could see a return to more restrictive pre-pandemic rules.
If telehealth rules become less flexible, you might need to:
- Revert to in-person service requirements for certain payers: Some payers might again require in-person visits for certain services to be fully reimbursed, especially for initial assessments or certain diagnoses.
- Carefully track place of service: You’d need to be even more meticulous about using the correct Place of Service code, ensuring it accurately reflects where the service is being delivered from – which could become more complicated if the rules tighten.
- Communicate changes to patients: If reimbursement changes impact what services you can offer via telehealth, you’d need to clearly communicate these changes to your patients.
Audio-Only (Phone) Sessions
During the public health emergency, many payers, including Medicare, expanded coverage to include audio-only telehealth for behavioral health. This has been crucial for reaching patients who lack reliable internet or video capabilities. The future of audio-only reimbursement is another area to watch.
If audio-only reimbursement is reduced or eliminated:
- Impact on access: You might have to reduce or eliminate phone sessions for some patients, which could disproportionately affect those with limited technology access, potentially reducing overall patient access.
- Revenue impact: If you heavily rely on audio-only sessions, a change in reimbursement could significantly impact your practice revenue. You might need to explore other service delivery models or adjust your fees accordingly.
- Patient communication: Again, clear communication with patients about covered telehealth modalities would be essential.
Interstate Practice and Licensing
Telehealth has blurred state lines. While some temporary waivers have eased interstate practice, the long-term rules are still evolving. Changes here could impact practices that serve patients across state borders.
If interstate practice rules become stricter:
- Licensing compliance: You’d need to ensure all your clinicians are properly licensed in each state where their telehealth patients reside, which could increase the administrative burden and potentially limit your service area.
- Billing complexities: Billing across state lines can already be complex. Stricter rules might add further layers of complexity, requiring careful attention to payer-specific and state-specific regulations.
2. Mental Health Parity: Could Stronger Enforcement Change Claim Denials?
Mental Health Parity laws are designed to ensure that insurance coverage for mental health and substance use disorders is equal to coverage for physical health. In theory, this means you shouldn’t face higher co-pays, stricter pre-authorization requirements, or limitations on the number of visits for mental health compared to, say, visits for a physical ailment.
While parity has been the law for years, enforcement is becoming a bigger focus. What could this mean for your practice and your billing?
Increased Scrutiny on Payers
Regulators are starting to put more pressure on insurance companies to prove they are truly complying with parity. This could lead to increased audits and investigations of payer practices.
Potentially, stronger parity enforcement could lead to:
- Fewer unfair denials: You might see fewer claim denials that seem to be based on discriminatory practices against mental health – things like blanket denials for certain diagnoses or limitations on therapy sessions that aren’t applied to physical health treatments.
- More successful appeals: If you do experience denials that seem to violate parity, stronger enforcement could mean you have a better chance of winning appeals by citing parity laws.
- More transparent benefit designs: Payers may be pushed to make their benefit designs more transparent, making it easier for you and your patients to understand what’s covered and at what cost for mental health services.
Focus on Network Adequacy
Parity also includes the idea of “network adequacy.” This means payers must have a sufficient network of mental health providers to meet patient needs, just as they must have adequate networks for physical health. Improved network adequacy could:
- Reduce out-of-network burden: If payer networks are truly adequate, fewer patients should need to seek out-of-network care, potentially reducing administrative burden related to out-of-network billing and patient reimbursement issues.
- Referral networks: Stronger networks could also make it easier to find appropriate in-network referrals for your patients when needed.
3. Value-Based Care: A Slow Shift in Behavioral Health Reimbursement
Value-Based Care (VBC) is a different way of paying for healthcare that’s gaining traction, especially in physical health. Instead of Fee-for-Service (where you’re paid for each session, regardless of outcome), VBC ties reimbursement to the quality and effectiveness of care, and sometimes to controlling costs. While VBC is less common in behavioral health now than in physical health, this is an area that could gradually evolve.
What could a move towards VBC mean for your behavioral health practice?
Emerging Pilot Programs and ACOs
You might start seeing more pilot programs or Accountable Care Organizations (ACOs) that include behavioral health in value-based payment arrangements. These are still in early stages in behavioral health, but it’s a trend to watch. If you participate in VBC programs:
- New payment models: You might encounter payment models beyond simple Fee-for-Service. These could include:
- Bundled payments: A single payment for an “episode” of care, like treatment for depression, rather than per-session payments.
- Shared savings: You could earn bonuses if you keep patient costs down while meeting quality benchmarks.
- Capitation: You might receive a fixed payment per patient per month, regardless of how many sessions they use, incentivizing you to manage their overall behavioral health needs proactively.
Quality reporting becomes important. VBC relies heavily on measuring quality. You might need to start tracking and reporting on patient outcomes, patient satisfaction, and adherence to evidence-based practices.
Focus on Integrated Care
VBC often encourages “integrated care,” where physical and behavioral health services are combined. Payment models may incentivize practices that effectively coordinate care across these domains. If integrated care models become more prevalent:
- Workflow adjustments: You might need to adjust your workflows to better coordinate care with primary care physicians or other physical health providers. This could involve developing referral processes, shared care plans, or even co-location arrangements.
- Coding for care coordination: You might need to learn new codes related to care coordination and inter-professional consultation if you move towards integrated care.
Prepare, Don’t Panic
Understanding 2025 behavioral health billing changes might seem daunting, but by focusing on the key potential shifts in telehealth, parity, and value-based care, you can start preparing your practice now and navigate the future billing landscape confidently. The key is to stay informed, review your current processes, and be ready to adapt. You don’t need to panic about massive overhauls. Instead, take these practical steps to ensure your practice is resilient and ready to navigate whatever billing changes 2025 may bring.
And remember, you’re not alone in this. Medisys is dedicated to supporting behavioral health practices through these evolving times. We continuously monitor billing changes and translate them into actionable guidance for our clients. If you need expert support in navigating the complexities of behavioral health billing and preparing for 2025, please reach out for a consultation. We’re here to help you focus on what matters most: providing excellent care to your patients.
