Connecticut insurers denied more behavioral health claims in 2014, according to an annual report card issued by the Connecticut Insurance Department. How much more depends on how you crunch the numbers.
Each year since 2006, the state agency charged with regulating the insurance industry has issued a report card comparing Health Maintenance Organizations or HMOs and up to 15 insurers with the highest premium volume in Connecticut that offer managed care plans.
The report compares the track record for each insurer on requests and denials for services and appeal outcomes.
Managed care plans use a process called utilization review to decide if a client should get health care that they or their provider have requested. The report shows that most utilization review requests, and subsequently most total and partial denials, were for outpatient services followed by extensions of stay.
The utilization review statistics for 14 indemnity managed care companies for the calendar year 2014 show the overall percentage of denials ranging from zero for Celtic, Golden Rule, HPHC and John Alden to 18.27 percent for CIGNA H&L and 13.16 percent for Time, or an average of 6.5 percent.
That represents a 41 percent increase from the average denial rate of 4.6 percent by 11 insurers in 2013. Denials ranged from zero for Celtic, Golden Rule, John Alden and Time to 11.47 percent for Anthem and 10.78 percent for Oxford Health in 2013.
Eliminating insurers with no denials would increase the rate even higher, to 70 percent in an analysis by the Connecticut Health Investigative Team.
The purpose of the report is to assist consumers with decision making, but even the Insurance Department admits the report could be more user friendly. The report does not include prior year data to help track trends year to year. That will change when the next report card is released in October, said spokeswoman Donna Tommelleo.
“We’re just going to change the format, just make it better looking and more useful,” said Tommelleo, adding that the next report will look back at least three years to reflect increased enrollments in 2014, the first full year of operation for Access Health CT, the state’s health care exchange established in response to the Affordable Care Act.
Last year, the state’s Behavioral Health Working Group was convened by the Insurance Department to study the utilization review process and data collection. Based on the working group’s work, the department has agreed to collect additional data on authorization and denial of medical necessity coverage by type and level of treatment, as well as denials of medical necessity requests and appeal outcome by type and level of treatment.
Comparing reports shows the percentage of denials that were appealed fell by more than half – from an average of 26 percent in 2013 to 12 percent in 2014. Some of those denials were successfully appealed: The percentage of appealed denials that were reversed decreased slightly from about 6 percent in 2013 to 5.5 percent in 2014.
Hours spent on the phone and emailing insurance companies to secure pre-authorization and fight denials have become increasingly burdensome for psychologists said Traci Cipriano, J.D., Ph.D., director of professional affairs for the Connecticut Psychological Association.
Cipriano said she wouldn’t be surprised if some psychologists decided not to follow up on some appeals. “Some will spend a day a week just doing paperwork,” she said. “Claims denials for things like clerical errors are frustrating.”
Cipriano suggested that many psychologists are choosing to go off the insurance grid altogether because of the uphill battle to get reimbursed at rates that reflect the significant level of education and training their profession requires.
“We don’t have hard data on this, but we do know many psychologists across the state do not take insurance, particularly in Fairfield County,” she said.
Tommelleo said that the Insurance Department’s Market Conduct Unit is conducting a more comprehensive review of carriers after identifying two carriers as outliers for denied utilization review determinations.
“That’s as specific as I can be because the reviews are ongoing,” she said. Once the reviews are completed, Tommelleo said the findings will be posted on the department’s Web site.
National Alliance for the Mentally Ill Connecticut Public Policy Director Daniela Giordano, MSW said the report’s findings did not surprise her.
“We do hear it on a regular basis that people are having all sorts of different issues of getting the care covered that their health care professionals are saying would be recommended,” Giordano said.
Giordano said there is a need to dig deeper to determine what the numbers actually mean. For instance, the report shows mixed results in the number of inpatient admission utilization review requests.
Such requests dropped 65 percent for Aetna Health, 45 percent for ConnectiCare and 60 percent for Oxford. But Anthem saw a 27 percent increase while CIGNA requests quadrupled.
Oxford had denied nine of the 134 inpatient admissions requests it received in 2013 but approved every one of the 53 received in 2014. Inpatient admissions denials all dropped: 63 percent at Aetna, 50 percent at ConnectiCare and 18 percent at Anthem.
“Having this data is really good,” Giordano said. “It’s a good start but it’s nowhere near enough about what is actually causing those numbers.”
A rise in inpatient admissions would not necessarily be good news, Giordano explained.
“We want people to not have to need inpatient or emergency room care because most things happen earlier on, just like any other health condition.”
By Janine Weisman