Since the World Health Organization (WHO) declared COVID-19 a Public Health Emergency of International Concern (PHEIC) and social distancing became part of our everyday vocabulary, the demand for mental health treatment has increased and, even today, continues to outpace available resources. In fact, according to the Centers for Disease Control and Prevention (CDC), suicide rates in the United States reached a record high in 2022 – 14.9 deaths for every 100,000 people. Fortunately, despite these heartbreaking numbers, behavioral and mental health is slowly becoming destigmatized, with the number of adults receiving treatment increasing year over year.
With that context in mind, behavioral health conditions have become increasingly prevalent for those seeking disability benefits. Individuals contending with any number of conditions falling within the mental and/or behavioral health spectrum may find themselves unable to work and, therefore, seek financial assistance afforded to them through disability insurance benefits. This gets complicated because, despite the increasing numbers of behavioral health claims, they remain among the most complex to manage and adjudicate and often require additional clinical and/or vocational assessment to help make the appropriate decision.
Seeking disability benefits with a behavioral health condition
For individuals seeking disability insurance benefits, medical evidence that details the full impact of their condition is the most important evidence to support their application. Some individuals may be suffering from a condition that is hard to explain and difficult to diagnose with a routine examination. While this does not make the condition any less impactful, an all-too-familiar challenge associated with behavioral health conditions is that the treatment records are viewed through a subjective lens versus an objective one, which is needed to make a decision.
In instances where medical records are unavailable or unable to support the claim, additional information may be needed to help identify the extent to which psychosocial issues impact a claimant’s functionality. Evaluating functional capacity is a key component within any claims organization; without it, disability claims managers cannot make a well-informed determination surrounding return-to-work facilitation, ongoing claim management, and general claim decision-making.
To understand a claimant’s functionality, one can either utilize in-house clinicians on staff or outsource the request to a vendor partner for an independent medical peer review. During an independent medical peer review – or medical file review – a board-certified physician, registered nurse, or vocational consultant reviews the entire file to address and determine how an individual is able to function within the confines of their disability. The medical peer does not decide if an individual is disabled but rather only determines whether, with the information reported, an impairment exists that impacts functionality. Whichever determination is made, an explanation is required to help the disability claims manager make an informed decision based on their request.
At the core, any request for a medical file review requires the same steps. When a request comes through to review a file with a behavioral health condition, an assessment can be made using the Global Assessment of Functioning, or GAF. GAF is used to determine how much an individual’s behavioral and/or mental health condition impacts their daily life on a scale of 0 to 100. The assessment was designed to help medical providers understand how well the person can complete everyday activities within the confines of their mental and/or behavioral health condition – the higher the score, the less impact on functionality.
An increase in behavioral health assessments
Over the past few years, we have seen an uptick in the number of requests for file review referrals with a behavioral health diagnosis, including psychology, psychiatry, and neuropsychology. In fact, at Brown & Brown Absence Services Group, we saw a 250% increase in behavioral health referrals in January 2022 versus January 2020 and a 97% increase in September 2023 compared to January 2020. In looking at psychology referrals specifically, numbers tripled in 2022 compared to 2020.
What’s leading to the increase in the request for mental and/or behavioral health assessments? Several factors could influence this behavior, including:
- An increase in behavioral health diagnoses and subsequent treatment for the condition(s);
- A delay in or a complete lack of behavioral health treatment and increased claimant self-reporting;
- A smaller investment by carriers in behavioral health resources as opposed to physical health conditions;
- A lack of available in-house resources to interpret medical records appropriately; and,
- Subpar medical records, which then require additional follow-up with providers.
The impact of behavioral health cases on the book of business
When a behavioral health diagnosis is listed as a comorbidity to a primary condition or as a primary condition with supplemental comorbidities, claim complexity generally exists, often extending claim duration. Extended duration only places an unnecessary hold on dollars sitting in already overextended reserves.
Brown & Brown Absence Services Group has the seasoned resources available and ready to assist you in completing a medical file review and other claim management solutions to help fully formulate the next steps in a claim and support a thriving organization. Reach out to us today to discuss how we can help your organization.