August 21st, 2013

Courts, governments scrutinize insurers

State governments and courts are scrutinizing whether insurers are complying with laws meant to ensure care for the mentally ill.

Massachusetts Attorney General Martha Coakley this spring sent a letter to America’s Health Insurance Plans (AHIP), urging the industry to comply with state law requiring coverage of necessary mental health services.

The AG’s Health Care Division has obtained seven settlements since 2007 alleging carriers failed to cover mandated mental health services, amounting to $9.2 million in payments to consumers and the state, according to Jillian Fennimore, deputy press secretary for the attorney general’s office.

“Compliance with the law is not optional,” Fennimore says. “Carriers have cooperated with our investigations and voluntarily entered consent judgments to resolve alleged violations of law. The settlements we have reached to date, with some of the largest carriers in the nation, have broad effect upon how they sell health care coverage in Massachusetts.”

“We all benefit from access to fair and legal health plans,” Fennimore says. “Carriers that fail to comply with our mandated benefit laws expose individuals and families to illegal limits on physical and mental health coverage that may result in adverse health and economic consequences.”

In a written response to Coakley’s letter, AHIP President and CEO Karen Ignagni says AHIP does not provide specific legal/compliance advice to individual members, but will continue to provide information, educational materials, compliance updates, webinars and other resources to support them in meeting applicable federal and state laws.

Also in the spring, a federal court in Vermont became one of the first courts to interpret the Mental Health Parity and Addiction Equity Act of 2008, when it denied a request by Fletcher Allen Health Care to dismiss a complaint from a woman who alleged that the company’s health plan violates the parity act by requiring pre-approval for routine, out-of-network mental health services, but not for routine, out-of-network medical services.

In “C.M. v Fletcher Allen Health Care, Inc.” Fletcher Allen argued that the plaintiff must establish that any difference between the plan’s provisions governing mental health and medical benefits is not attributable to “recognized clinically appropriate standards of care” which permit those differences, as allowed under the parity act. However, the court ruled that it is not the patient’s responsibility – but rather, it is the insurer – that bears the burden of proof to provide plan participants and beneficiaries with the criteria for medical necessity determinations and an explanation for any denial of reimbursement or payment for services.

In Conn., the state Insurance Department announced that Anthem Health Plans agreed to adjust its medical billing code reimbursement procedure for payments to behavioral health providers and reprocess approximately 28,000 claims – for about $400,000 in additional payments – retroactive to Jan. 1.

Connecticut Insurance Department Deputy Commissioner Anne Melissa Dowling says the department had received several complaints as part of its normal complaint process and pursued the issue with Anthem. Dowling says the department was expecting a final report from Anthem in August, but had received a preliminary report indicating that Anthem began reprocessing payments in June. “It looks like they are on track,” and that providers had been notified, Dowling notes.

Sarah Yeager, director of public relations for Anthem Blue Cross and Blue Shield in Connecticut, says Anthem had adopted new fees to match changes to the procedure codes associated with behavioral health services implemented by the American Medical Association and effective Jan. 1 of this year. “Originally in establishing the compensation levels for the new codes, Anthem sought to preserve the level of payment in the aggregate that behavioral health providers were receiving before the code changes to keep them budget neutral,” Yeager says. “After receiving feedback from psychiatrists and other behavioral health providers, and in close cooperation with our regulator, the Conn. Department of Insurance, and with input from the Office of the Attorney General, we decided to revise our professional fee schedules for behavioral health services to more closely align with expected coding patterns. Anthem continues to cover all behavioral health services, including psychotherapy, in accordance with our members’ health benefit plans.”

Despite the agreement, a lawsuit filed in federal court in April is alleging that Anthem discriminates against mental health care patients in violation of the parity act. The suit was filed on behalf of the American Psychiatric Association, Connecticut Psychiatric Society, Connecticut Council of Child and Adolescent Psychiatry, and two individuals, and alleges that the insurance company failed to properly adopt the CPT codes effective Jan. 1 and did so in a manner that drives psychiatrists out of their networks and thus places upon mental health patients greater burden and expense than those seeking non-mental health care services.

“Despite legislation which makes it illegal to discriminate against mental health treatment, stigmas still exist and access to quality care remains a challenge in many cases,” says Attorney Maria Pepe VanDerLaan of the firm Murtha Cullina, who represents the plaintiffs.

“Because hurdles exist, those who need care suffer greater financial burdens and investments of time when they are most vulnerable. Simply stated, this needs to stop,” VanDerLaan says.

By Pamela Berard

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