Firms place limits on mental health treatment

By Elinor Nelson
July 1st, 2010

Psychologists may be seeing more managed care from their patients’ insurers. Faced with increasing costs, some employers and insurers are controlling utilization by authorizing limited numbers of sessions and requiring forms or phone calls to allow additional sessions.

A year ago, one major employer changed its policies. That party was the Group Insurance Commission, which insures about 180,000 Massachusetts state employees and retirees and their dependents, totaling about 340,000 people. Executive Director Dolores Mitchell explains the changes actually affect the policies of about 294,000 of those people, and amounts to about the approximately 10 percent of that group who access mental health and substance abuse care.

The policy change impacts services provided by out-of-network mental health providers for the GIC-insured of Tufts Health Plan, Harvard Pilgrim Health Plan and Unicare, which are managed by United Behavioral Health.

According to Mitchell, the GIC “had decided it was time to bring in more care management [regarding] a very generous and fairly unmanaged portion of the mental health program administered by out-of-network providers.” Years ago, she explains, the out-of-network providers for those plans had been limited to 15 sessions per year. Over time, that practice was loosened to no limits as long as treatment met “general professional standards.” In contrast, in-network providers had care that was already being managed.

“We don’t arbitrarily make changes,” says Mitchell, noting that the GIC decided to initially authorize 10 sessions – no questions asked – and then ask the out-of-network provider to fill out a form (using information from the treatment plan) if additional sessions were desired. After that, another 10-12 sessions could be authorized. Beyond 22 sessions, the provider would need to participate in a phone consultation with a UBH professional in order to obtain authorization for more sessions. The telephone conversation, she adds, was supposed to take only eight to nine minutes. “The care management,” says Mitchell, “is not just a money saver. It provides for better care.”

Matt Selig, J.D., executive director of Health Law Advocates, a Boston-based nonprofit public interest law firm, has heard from providers who are finding that services they are convinced are medically necessary are more often being denied at the outset or that coverage is only approved for a few visits with justification required for continued treatment. Phone consultations, they say, can be lengthy and burdensome, as well. As a rule, Selig states, mental health and substance abuse services “seem to be subject to a higher scrutiny.” The GIC is not the only employer increasing its care management.

Might there be violations of the federal Mental Health Parity Act, enacted in 2008? “Given the complexity of the Act, it’s premature to say that there might be a violation. It doesn’t help the discussion,” says Mitchell. Selig agrees that interpreting the federal law can be a challenge. While the consensus, Selig says, is that the federal regulations – expected to be finalized on July 1 – are “very consumer friendly,” the law says that health plans cannot use more stringent utilization review practices for mental health claims than for medical claims. As a result, a health plan must be looked at “as a whole and at the limits applied to most or all of its services,” says Selig.

As of New England Psychologist’s deadline, the Massachusetts Psychological Association had not replied to requests for comment on this issue.

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