Holding Insurers Accountable for Parity in Coverage of Mental Health Treatment.

Paul S. Appelbaum and Joseph Parks
Psychiatric Services 
Originally posted 14 Nov 19

Despite a series of federal laws aimed at ensuring parity in insurance coverage of treatment for mental health and general health conditions, patients with mental disorders continue to face discrimination by insurers. This inequity is often due to overly restrictive utilization review criteria that fail to conform to accepted professional standards.

A recent class action challenge to the practices of the largest U.S. health insurer may represent an important step forward in judicial enforcement of parity laws.

Rejecting the insurer’s guidelines for coverage determinations as inconsistent with usual practices, the court enunciated eight principles that defined accepted standards of care.

In 2013, Natasha Wit, then 17 years old, was admitted to Monte Nido Vista, a residential treatment facility in California for women with eating disorders. At the time, she was said to be suffering from a severe eating disorder, with medical complications that included amenorrhea, adrenal and thyroid problems, vitamin deficiency, and gastrointestinal symptoms. She was also reported to be experiencing symptoms of depression and anxiety, obsessive-compulsive behaviors, and marked social isolation. Four days after admission, her insurer, United Behavioral Health (UBH), denied coverage for her stay on the basis that her “treatment does not meet the medical necessity criteria for residential mental health treatment per UBH Level of Care Guidelines for Residential Mental Health.” The reviewer suggested that she could safely be treated at a less restrictive level of care (1).

Ms. Wit’s difficulty in obtaining coverage from her health insurer for care that she and her treaters believed was medically necessary differed in only one respect from the similar experiences of thousands of patients around the country: her family was able to pay for the 2 months of residential treatment that UBH refused to cover.

The info is here.

Wit et al. vs. United Behavioral Health and Alexander et al. vs. United Behavioral Health

U.S. Federal Court Finds United Healthcare Affiliate Illegally Denied Mental Health and Substance Use Coverage in Nationwide Class Action

• Landmark Case Challenges the Nation’s Largest Mental Health Insurance Company for Unlawful, Systematic Claims Denials – and Wins

• Groundbreaking Ruling Affects Certified Classes of Tens of Thousands of Patients, Including Thousands of Children and Teenagers 

• Judge Rules, “At every level of care that is at issue in this case, there is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions.”

In a landmark mental health ruling, a federal court held today that health insurance giant United Behavioral Health (UBH), which serves over 60 million members and is owned by UnitedHealth Group, used flawed internal guidelines to unlawfully deny mental health and substance use treatment for its insureds across the United States. The historic class action was filed by Psych-Appeal, Inc. and Zuckerman Spaeder LLP, and litigated in the U.S. District Court for the Northern District of California.

The federal court found that, to promote its own bottom line, UBH denied claims based on internally developed medical necessity criteria that were far more restrictive than generally accepted standards for behavioral health care. Specifically, the court found that UBH’s criteria were skewed to cover “acute” treatment, which is short-term or crisis-focused, and disregarded chronic or complex mental health conditions that often require ongoing care.

The court was particularly troubled by UBH’s lack of coverage criteria for children and adolescents, estimated to number in the thousands in the certified classes.

“For far too long, patients and their families have been stretched to the breaking point, both financially and emotionally, as they battle with insurers for the mental health coverage promised by their health plans,” said Meiram Bendat of Psych-Appeal, Inc. and co-counsel for the plaintiffs who uncovered the guideline flaws. “Now a court has ruled that denying coverage based on defective medical necessity criteria is illegal.”

In its decision, the court also held that UBH misled regulators about its guidelines being consistent with the American Society of Addiction Medicine (ASAM) criteria, which insurers must use in Connecticut, Illinois and Rhode Island. Additionally, the court found that UBH failed to apply Texas-mandated substance use criteria for at least a portion of the class period.

The legal opinion is here.

We live in a culture of mental health haves and have nots

Naomi Freundlich
KevinMD.com
Originally published July 4, 2016

Here is an excerpt:

Let’s start with enforcement. Multiple agencies oversee compliance with the parity laws, including state insurance boards, Medicaid, HHS or the Department of Labor, depending on how and where an individual is insured. Figuring out who to contact when there’s been a violation of parity laws can be difficult, especially when people are experiencing mental health problems.

Furthermore, although obvious discrepancies between behavioral and medical coverage are not all that common, according to Kaiser Health News, many insurers have figured out how to limit mental health costs through more subtle strategies that are harder to track. These include frequent and rigorous utilization review and so-called “fail first” therapies that require providers to try the least expensive therapies first even if they might not be the most effective. The KHN authors note, “Among the more murky areas is ‘medical necessity’ review — in which insurers decide whether a patient requires a certain treatment and at what frequency.”

A survey conducted by the National Alliance on Mental Illness found that patients were twice as likely to be denied mental health care (29 percent) based on “medical necessity” review than other medical care (14 percent).

The article is here.