Managing Behavioral Health Disability Claims

By Phil Lacy, ADL Absence Health and Productivity Practice Leader, Marsh McLennan Agency

Anxiety disorders affect more than 40 million adults in the U.S.¹ Generalized anxiety disorder (GAD), a mental health condition, affects 6.8 million adults annually² and is a common cause of workplace disability and unemployment.³

GAD symptoms — which include irritability or edginess, rapid heart rate and breathing, fatigue, concentration problems, sleep disturbances, and gastrointestinal problems — can be subjective, which can make it difficult for absence and disability managers to manage leaves.

Anyone can experience feelings of anxiety at different times. But when these feelings lead to ongoing distress and impair daily functionality, employees can miss work.

The percentage of short-term disability (STD) claims for behavioral health conditions in the Mental and Nervous Disorders diagnostic category nearly doubled from 2000 to 2021.^4,5 And mental health issues, including depression and anxiety, are among the top five reasons for STD claims.⁵

Knowledge Is Power

Absence and disability managers must validate the severity of employee symptoms that justifies time away from work for treatment and recovery, which can be difficult. Good case management requires specialized training and tools for this type of assessment. For example, learning how to determine severity of mental health symptoms can help these managers make a disability determination, and learning how to work with a primary care provider when an employee is not being seen by a psychiatrist or psychologist can help absence management teams work more effectively with employees.

Employers must also ensure that they engage and communicate with employees who are experiencing GAD and depression. These actions can improve outcomes and return-to-work time frames. Below are a few areas of vulnerability identified during behavioral health claim audits² for anxiety and depression:

Claim approvals based on an employee’s self-reported symptoms with no documentation as to the level of severity requiring time off from work
Employees requesting a specific disability start date three to four weeks from when they call in the need for leave for anxiety and depression
Diagnosis from a primary care physician — a patient may be referred for therapy and placed on a medication, but the case manager didn’t follow up for therapy notes and uses the attending physician statement (APS) as the information source to justify a claim decision
Providers who prescribe a medication with no referral for therapy and take the employee out of work for four weeks to allow the medication to titrate

To elaborate on the last bullet, regarding medication, it’s important to note that not all medications work for people with anxiety and depression, conditions that can delay a patient’s ability to return to work by four weeks or more. And medication alone does not normally cause side effects that would prohibit an employee from working. In addition, an employee’s self-reported symptoms provide no documentation on level of severity.

Appropriate Care and Treatment

When patients with GAD receive psychotherapy, a recovery rate of approximately 57% can be achieved. However, this rate could be 60% to 70% if treatment includes medication or alternative therapies such as inpatient or outpatient therapy.

Durations of disability can be longer when employees are not receiving treatment from mental health specialists. In one study of individuals with anxiety and depression, 63% were treated by behavioral health specialists; in another study, only 50% received care from specialists as shown in the graphs. To shorten employee time away from work, employers are encouraged to ensure that their employees can get access to mental health professionals as quickly as possible.

Medical doctors are licensed to treat mental health and may be appropriate providers for cases of moderate mental illnesses when medication is prescribed with referrals for therapy if needed. But if employees require more than 30 days away from work for treatment, many employers now require that treatment be provided by a licensed psychiatrist, psychologist, or mental healthcare professional/licensed social worker/counselor working under the direct supervision of a licensed psychiatrist.

One way to shorten an employee’s time away from work is genetic testing, which identifies what medications an employee can titrate so a provider knows which medications to prescribe. This practice can reduce the duration of disability by days if not weeks. Some tests cost less than $350 — a cost that employers are including in their prescription plans as cost savings from the shortened time away from work, a savings that more than covers the cost of the test.

Best Practices

Documenting the severity of GAD and depression symptoms continues to be a challenge. The best approach to quickly and efficiently gather the right information is to send the treating provider a behavioral health APS that requires information about:

cognitive functioning (applied focus in minutes, memory tests, numeric tests);
emotional and behavioral observations (appearance, speech, motor activity, mood with a range from euphoric to irritable to depressed);
cognition (orientation, memory, attention);
perception (hallucinations, speech, delusions);
thoughts (suicidality, homicidality, delusions);
behavior (cooperative, aggressive);
insight (a range from good to poor);
judgment (a range from good to poor);
activities of daily living (ability to function in a work environment, significant weight gain or loss, appetite changes, sleep disturbance, panic attacks and frequency); and
treatment (history of GAD, dates of treatment, inpatient care, medication management, outpatient therapy, patient’s progression as a result of treatment).

If the employee is being treated by a primary care provider and was referred for therapy, the case manager should request a completed APS from the therapist and therapy notes from previous therapy sessions once a medical release is signed.

When a treating provider is unable to provide adequate documentation to support a claim decision, a peer-to-peer conversation (also called a clinical consultation) is necessary between a vendor’s clinical team and the employee’s providers to get the information needed to support a request for time off. Sending the employee for an independent assessment can also help determine the level of severity, and it can be used as a second opinion in cases with limited or conflicting documentation.

Anxiety and depression claims can be some of the most complex and difficult to manage. With the right tools and resources, a case manager can make a fair and informed claim decision more efficiently. Recommendations include:

Use case managers who are trained in behavioral health or behavioral health nurses who are supported by in-house or contracted psychiatrists to facilitate the claim management process.
Use the initial interview between an employee and case manager as an opportunity to understand the employee’s situation; past history; and all treating physicians, therapists, and other resources tapped, and to set expectations for the information needed to render the initial claim decision.
Create a detailed behavioral health APS for providers to document an employee’s diagnosis, symptoms, and the level of severity of symptoms.
Be open to alternative treatment specialists. Employers can require that treatment is provided by a specific behavioral health provider after a certain period of time, but there should be flexibility if employees are in locations where it is difficult to find providers or when it takes weeks or months to see a specialist. Telehealth is also a viable alternative when local mental health providers are not available.
Evaluate integrated care models in which primary care and behavioral health clinicians work together with your employees using a systematic, cost-effective approach to provide patient-centered care. This care may address mental health and substance use disorders, including their contribution to chronic medical illness (life stressors and crises, stress-related physical symptoms, and ineffective patterns of healthcare use).

Navigating the System

In a study published in the Journal of General Internal Medicine, patients with depression treated exclusively by primary care providers have attitudes and beliefs more averse to care than those seen by mental health specialists. These differences in attitudes and beliefs may contribute to lower quality depression care.

For employees who require more serious care on an inpatient basis, network access is extremely limited. In fact, patients are 5.2 times as likely to go out of network for inpatient mental health care, according to a 2019 Milliman study.⁶

Cost becomes a barrier with many conditions requiring multiple admissions and ongoing care. Your employees, potentially at very high risk, face long waiting lists; issues with fraud, waste, and abuse within certain providers, specifically around substance use disorder; and the high costs and potential for balance billing that goes along with out-of-network care.

These employees hopefully continue seeking care and find the treatment solution to manage their condition. But there is no quick fix. In fact, 70% of patients do not recover from their first treatment alone. When it comes to mental health, your employees don’t know what benefits they have; are afraid to use those benefits; and need help navigating a complex insurance model that does not offer the same level of care, support, and triaging of benefits like it does for physical conditions.

The complexity for employees to navigate an already difficult healthcare system to find appropriate care that focuses on return to function creates a unique set of challenges for the disability claims professional when employees become unable to work as a result of their mental illness.