Reimbursement Potential of Collaborative Care Model (CoCM) Billing Codes for Opioid Use Disorder Co-Occurring with Mental Disorders: Descriptive Estimates from a Pragmatic Trial

In 2017, the U.S. Centers for Medicare and Medicaid Services approved reimbursement for billing codes specific to the Collaborative Care Model (CoCM), an evidence-based practice for improving access and quality of behavioral health services in primary care. However, it remains unclear how reimbursement through these billing codes aligns with applications of CoCM for complex patient populations, such as those with co-occurring mental and substance use disorders. We examined the reimbursement potential of CoCM intervention activities documented during a pragmatic clinical trial of CoCM for patients with opioid use disorder co-occurring with depression and/or post-traumatic stress disorder. We defined reimbursement potential based on federal (i.e., Medicare) CoCM billing code rules and reimbursement rates, as of 2024. Across 381 patients and 10 care managers (i.e., the CoCM interventionists), we documented 90,996 total intervention activity minutes in the project’s care management registry. Under ideal conditions where all CoCM billing codes can be and are used, a maximum of 56% of minutes would be billable, generating $91.61 reimbursement per hour of care management. Reimbursement potential was lower under restrictive billing conditions and settings, resulting in $79.32 per hour. Most commonly, minutes were unbillable due to not meeting CoCM service requirements or exceeding maximum billable time for a month. Sensitivity analyses showed that reimbursement potential could be notably lower in alternative scenarios (e.g., $39.63–$43.04 per hour with minimum plausible Medicaid billing rates). Continued attention is needed to align CoCM reimbursement potential with clinical needs to ensure feasibility and sustainability with complex patient populations.