Connecticut report assesses coverage rates

By Janine Weisman
April 1st, 2017

Connecticut’s top insurers denied fewer claims for mental health services in 2015 than the year before even as they continued to reject claims for residential care at high rates, according to a recent state report.

Eight managed care insurance companies rejected about 6.4 percent of claims for mental health services, an analysis of the 2016 Consumer Report Card released by the Connecticut Insurance Department shows. That’s compared to the roughly 8.3 percent of mental health claims submitted in the previous year.

For nearly two decades, the state agency charged with regulating the insurance industry has published an annual report providing an overview of Connecticut’s health insurance managed care landscape.

The 2016 report card released last October compared care measures and member satisfaction surveys from six health maintenance organizations and 11 indemnity companies that have a total enrollment of more than 2.4 million members.

It features a revised format to make it easier for consumers to understand, according to an introductory note from Insurance Commissioner Katharine Wade.

Managed care plans use a process called utilization review to decide if clients should get health care they or their provider have requested. The new report card shows more than 198,000 beneficiaries received care for a mental health service in 2015, with most seeking treatment in an emergency room or as an outpatient.

Only 2.5 percent of the 165,249 indemnity plan members who received any mental health service did so as an inpatient. Similarly, 2.4 percent of the 32,899 health maintenance organization members who received a mental health service were treated as an inpatient.

The 2016 report shows that residential behavioral health care had the highest rate of denials among half of eight top insurers.

Nearly one in three utilization review requests for residential care was rejected by Aetna Life, and Cigna H & L. HPHC denied one in five residential care requests. United denied about 14 percent while Anthem and ConnectiCare each denied about 11 percent. Oxford Health rejected about 10 percent. Connecticut General received no such requests.

In response to New England Psychologist’s request for comment on its 32 percent rate of denial for residential care utilization review requests, Aetna Life issued the following statement:

“We have taken a team approach to advocate for members, collaborate with health care providers to support high risk members and their families, address social determinants and we offer a variety of clinical options based on each individual’s specific needs. We use this approach when reviewing behavioral health claims for residential care – as well as other requests for care – and we strive to enable everyone to have access to needed services that achieve optimal emotional health and well-being.”

Rates of denial for acute inpatient care among the top insurers were generally low, between zero and 5 percent, the report card shows.

Daniela Giordano, public policy director for the National Alliance on Mental Illness Connecticut chapter, said of the higher rates of approval for mental health services are good news. But while the report card is helpful to consumers, Giordano said the information offered is narrow in scope.

“It also doesn’t tell you anything about whether people are getting access to treatment and services as early as possible,” Giordano said. NAMI Connecticut advocates for community-based care that could ultimately reduce the number of emergency room visits or hospitalizations.

The report card also doesn’t show how well insurers are doing when it comes to parity compliance, Giordano said. She would like to see future versions of the report card compare prior authorization requests for physical and mental health services, out of network approval rates, provider reimbursement rates and standards on applying medical necessity determinations.

The Connecticut Insurance Department uses the report card as a tool to monitor the market, spokeswoman Donna Tommelleo said.

Last year, the department’s Market Conduct unit found concerns with several health insurers on mental health and/or substance abuse issues such as incorrect mental health reimbursement fees, claim errors on out-of-network providers, improper processing of mental health lab service claims and incorrect co-payments charged for mental health office visits.

One insurer, ConnectiCare was fined $4,000 in February after a department investigation of 2014 utilization review practices. State examiners found ConnectiCare call center staff did not provide proper language for filing an appeal to a member and failed to designate a clinical peer uninvolved with initial adverse determinations in 20 overturned appeal determinations.

A letter from the company on the Web site outlines corrective actions to change its review process and train call center staff on member appeal rights. 

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