Mental Health Parity Law has more holes in it than Swiss Cheese

From director:

In treating people after the Mental Health Parity Law took effect, I’ve learned that this law has more holes in it than Swiss Cheese. I have listed some of the examples:

1. Only some insurance plans contain Mental Health Parity (it excludes private plans, some non-state plans, etc.).

Those with parity:
1. Exclude provider parity, meaning:
a. Providers who haven’t needed the business enough to join the panels will either not be covered, or will be covered with out of network benefits only (instead of major medical full coverage).
b. Providers without the credentials of the medical directors of many plans will be less covered than those with (typically an M.D. or D.O.):
i. For example, MHN (Healthnet) requires paperwork every 10 sessions by non-M.D. providers of mental health, which is time consuming and arduous, disallowing the provider from giving full attention to the actual case and instead focusing on redundant paperwork.
ii. Non M.D./D.O. providers will be reimbursed less in-network, meaning they must see many more patients to make up for this substantial pay reduction (imagine if suddenly your accountant/lawyer/physician got a 50% pay-cut!). And out-of-network, you’ll get less reimbursement, by as much as 50%, making it less affordable to see the more experienced people who typically charge what their M.D./D.O. counterparts charge.

2. Anthem Blue Cross Blue Shield, even Century Preferred, requires even more frequent paperwork, which often can’t be honestly done w/o patient participation, wasting sessions as often as every 4th.

3. I have a Bipolar client whom I saw twice per week, but then her Anthem Century Preferred plan cut it back to once per week. I sought a peer review through the appeals process, but they actually sent it off to non-peers (people w/o my credentials in family therapy) who held up the denial. This goes against my interpretation of the state statute, but the state/insurer was of no help when I alone tried to fight it.

4. I went so far as to go in person, unreimbursed, to the Anthem Medical Director to try and get my services covered better for my client’s Mom, but he denied me parity with people w/his credentials, even though I had much more therapy training (though clearly not medicine training) than most of the psychiatrists. I ultimately decided to give a deal to the clients by conditionally waiving part of their balance, but that then makes it harder on me to give them my all.

5. Quite some time after this incident with Blue Cross, for another client I was seeing under Blue Cross’s contracted out mental health HMO, Value Options, I was audited. I was never told why, but I had to then spend ~50 hours dealing w/the audit process. In the end it was determined that not only did I bill accurately for the mostpart, but where I made errors, I actually underbilled, so in the end Value Options had to send me a check for about $24. So, I earned $.48/hr. from the whole process. Do you have any idea how much good I could have done w/that time for my existing clients if I didn’t go through that audit?

6. Aetna used to cover all providers the same out of network, but in the fall of ‘06 they changed their policy and reimbursed their clients 40% less for the majority of mental health practitioners, w/o regard to the quality and training of those who got the reduction. Even if that saves Aetna $ in the short-run, if people don’t use the best providers as often due to finances, there can be much bigger and more costly problems that can cost Aetna more in the long-term.

7. Utilization management is not or hardly affected by the laws, since insurers can still place policies and do what they want for the mostpart, such as with a Bipolar Disordered person needing hospitalization, the insurer can say if someone isn’t actively trying to kill themselves or others, then they can’t get hospitalization. Sure the patient may attempt suicide and succeed at it a few days later when home at night, but still this is just how it works. Similarly, the insurer can say twice per week therapy only when in a crisis, *as they define it*, which means that the therapist has little to no say in what is defined as a crisis.

8. If you apply for an insurance plan individually, and you’ve had mental health history, most of the plans will deny you.

9. Solutions: I think the two solutions are:
a. Returning to pre-HMO/PPO days to when plans basically covered the coverable services without a a strong discrimination between types of providers. They also allowed more time in hospitals, etc.
b. Change insurance plans to what they were conceived of, at one time, catastrophic coverage. This can reduce premiums paid by individuals/employers, thus allowing more ability of individuals to seek out the healthcare they want. The closest we have are high deductible plans that can combine with a Health Savings Account. This combination gives people the ability to see who they want for how long they want, but the cost is shifted to the patients directly while they save indirectly through lowered priced premiums.

Sam Schaperow, MSMFT, LMFT


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