Determining the reasons insurers deny coverage of services can be a time-consuming, resource-draining task. But thanks to the combined advocacy efforts of the Massachusetts Neuropsychological Society (MNS) and the Massachusetts Psychological Association (MPA), consumers and practitioners will gain greater access to information with the passage of the “Transparency Bill.”
According to neuropsychologist Karen Postal, Ph.D., ABPP (CN), instructor of psychology in Harvard Medical School’s department of psychiatry, patients who received denial notices have the right to appeal individually to the Office of Patient Protection, a lengthy and frustrating exercise. She says insurers have “found a clever workaround” when it comes to paying for some services. Most insurers have adopted the practice of purchasing medical necessary criteria sets, which claim to be grounded in science, from for-profit companies. “These criteria sets took the place of provider opinion,” she says. “The insurance companies or large corporations who sell criteria sets say the science is proprietary and they won’t allow providers to see them.”
“The way the legislation came about was that MNS and MPA had cooperated for years around the issue. We met countless times and wrote letters and testified,” Postal says. MNS and the MPA repeatedly requested meetings with various insurers and companies that created the criteria sets. Postal reports that all their requests were denied. Undaunted, the two organizations pressed for legislation that would remove the barriers and make the information accessible to consumers and clinicians.
Michael Goldberg, Ph.D., director of Child and Family Psychological Services at Integrated Behavioral Associates in Norwood, Mass., also became involved in the bill’s conception. “It makes global sense to be able to dispute the criteria, to make sure they do meet the law. They have to be scientifically based and accepted in the medical community,” he says, adding that utilization review and protocols should also be available to the public.
The passage of this bill will allow the Office of Patient Protection to review entire medical necessary criteria sets for the first time, says Postal. “This is game-changing legislation, which will protect patients, psychologists and other health care professionals from restriction of access to necessary services based on secret/propriety medical criteria sets,” she says.
The efforts of the MNS and MPA received considerable support from the legal experts at the American Psychological Association, according to Postal. “The practice directorate has a wonderful legal team that helps states deal with unfair practices,” she says.
The passage of this law will benefit all medical disciplines, although psychologists were especially pleased, Postal adds. “The whole psychology community nationally is thrilled with the legislation. Someone will finally show us the evidence in evidence-based medicine, which will make healthcare cheaper and better.”
When the legislation will be implemented is unknown. Goldberg says, “This is all part of healthcare reform. If it were just a little bit of legislature, we would have a clear picture of an implementation date. But it’s a multi-step overhaul.”
By Phyllis Hanlon