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Showing posts with label Medical Necessity. Show all posts
Showing posts with label Medical Necessity. Show all posts

Saturday, April 6, 2019

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.

Monday, October 10, 2016

Federal Court Certifies Nationwide Class Action Challenging UBH Coverage Criteria

Press Release
Originally released September 20, 2016

In a significant mental health ruling, the United States District Court for the Northern District of California has come one step closer to ordering health insurance giant United Behavioral Health (UBH) to revamp its medical necessity criteria and reprocess thousands of outpatient, intensive outpatient and residential treatment claims it denied since 2011. Plaintiffs in two companion class-action lawsuits, Wit et al. v. UnitedHealthcare et al. and Alexander et al. v. United Behavioral Health, allege that UBH systematically denies coverage for mental health treatment by developing and applying "medical necessity" criteria that are far more stringent than generally accepted standards of care.

"Yesterday's class certification order is an important victory in the fight for mental health parity," said Meiram Bendat, president of Psych-Appeal, Inc. and co-counsel for the plaintiffs. "It signals that health insurers can be held responsible, on a class-wide basis, for denying insurance coverage for mental health treatment to those desperately in need. Without class certification, few, if any, patients will have the financial or emotional resources necessary to challenge this type of misconduct individually."

The plaintiffs' health plans, governed by the Employee Retirement Income Security Act (ERISA), require UBH to evaluate medical necessity according to generally accepted standards of care. UBH's proprietary medical necessity criteria purport to reflect these standards. However, the plaintiffs allege that a push for profits has led UBH to develop criteria that overemphasize acute mental health and substance use disorder symptoms and disregard chronic or complex conditions that require ongoing care, in contravention of generally accepted standards.

UBH is a subsidiary of UnitedHealth Group and is the country's largest managed behavioral health care organization, serving more than 60 million members.

Psych-Appeal, Inc. and Zuckerman Spaeder LLP have been appointed class counsel by the federal court and also represent plaintiffs in similar cases against Health Care Service Corporation (Blue Cross and Blue Shield of Illinois, Texas, New Mexico, Montana and Oklahoma), Magellan Health Services of California and Blue Shield of California.

The pressor is here.

Thursday, July 28, 2016

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.

Thursday, October 8, 2015

Is mental health 'parity' law fulfilling its promise?

By Jenny Gold
Kaiser Health News/CNN
Originally posted on September 20, 2015

Here is an excerpt:

The so-called parity law, which was intended to equalize coverage of mental and other medical conditions, has gone a long way toward eliminating obvious discrepancies in insurance coverage. Research shows, for instance, that most insurers have dropped annual limits on the therapy visits that they will cover. Higher copayments and separate mental health deductibles have become less of a problem.

But many insurers have continued to limit treatment through other strategies that are harder to track, according to researchers, attorneys and other critics. Among the more murky areas is "medical necessity" review -- in which insurers decide whether a patient requires a certain treatment and at what frequency.

Kamins is among a small group of people around the country to file lawsuits alleging federal or state parity laws were violated when patients with mental illness were held to a stricter "medical necessity" standard than those with other medical conditions.

The entire article is here.

Friday, February 27, 2015

Medical Necessity and Unnecessary Care

By Paul Keckley
The Health Care Blog
Originally posted January 29, 2015

Unnecessary care that’s not evidence-based—usually associated with excess testing, surgical procedures or over-prescribing—accounts for up to 30% of what is spent in healthcare. In recent months, enforcement actions against physicians and hospitals have gained increased attention. But unnecessary care and over-utilization is not a new story or one that’s easy to understand.

(cut)

What does it mean?

Documentation is key. Accurate clinical documentation across sites and systems of care is table stakes.

Transparency about medical necessity and unnecessary care is assured. Data about the performance of every practitioner, hospital, and health system will be widely accessible.

The entire blog post is here.

Thursday, January 29, 2015

Is My Work “Medically Necessary”?

How insurance companies try to get around rules for mental health care.

By Darcy Lockman
Slate
Originally published January 12, 2015

Here is an excerpt:

I’ve been in private practice since 2010. Most of the people I see submit their bills to their insurance companies for reimbursement. It’s a testament to the integrity in the industry that these reimbursements often come through without a hitch. (Though only in this era of predictable corporate malfeasance could a company simply making good on its contractual obligations be praised for its integrity.) Somehow, four entire years went by during which I never once had to submit to a utilization review. But in the past year, possibly because of increased cost concerns in the wake of the Affordable Care Act, I’ve received a handful of phone calls, each caller requesting that I schedule a talk with a case manager.

The entire article is here.