Insurance Networks and Mental Health Parity

I was invited to testify at a congressional forum last week by Congressman Chris Van Hollen about challenges in the implementation and enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA). Also present were Congressmen Jim Moran and Paul Tonko, and former Congressmen Patrick Kennedy and Jim Ramstad.  These dedicated representatives stayed past 9 p.m., reflecting their dedication and resolve to ensure that the Parity Act be fully implemented.

As most readers of Clinical Psychiatry News are aware, people with mental health and addiction problems have long been stigmatized and marginalized in the health care system, and this one action – passing the 2008 Parity Act – will prove to be a historic correction of this great wrong. Indeed, the first attempt to correct the discriminatory practices of the health insurance industry was passed in 1996, but the industry figured out how to get around the intent of that first Parity Act. The ongoing efforts to close these loopholes are currently stuck, with the lack of final regulations that would dictate to payers how MHPAEA will be implemented and enforced, despite the law being passed 4 years ago.

Even URAC, the standards-based accreditation organization that accredits health insurance plans, has beat the federal government by recently updating its standards to require health plans to clearly and effectively demonstrate compliance with the Parity Act. To my knowledge, this is the first organization to specifically build Parity Act compliance into its standards for accreditation.

There has been an interim final rule passed, but such temporary regulations lack the finality that makes health plans address the more challenging aspects of compliance, particularly the nonquantitative treatment limits, or NQTLs. One of the more pervasive, yet hidden, NQTLs is the inadequacy of behavioral health provider networks compared to that of primary care networks.

I believe that network adequacy is probably THE biggest barrier to accessing care for our patients. When I ask patients about any problems finding a primary care physician, they rarely have problems. But finding an in-network psychiatrist has become an overwhelming problem. The insurance plans do not maintain a large enough network of physicians who specialize in psychiatry, creating a bottleneck that makes it hard for patients to initiate treatment.

While there has been some reductions in the need to obtain prior authorizations for outpatient treatment, the loophole here is that if there are not enough psychiatrists in the network who can actually see the patients needing care, many patients go without. This effectively limits the number of claims a payer must pay out. This is a nonquantitative treatment limit that is more restrictive on the mental health and addictions side than on the physical health side.

You’d think that one could determine the adequacy of the network by the number of providers in it, but this number is not an accurate reflection of the true size of the network. Look more closely and you discover a number of tricks that inflate the apparent size of the network. Whether these “tricks” are intentional or not, they amount to – in my opinion – fraud. If you pay for a plan that has 40 doctors listed in its online provider directory, you expect that you can see most of these 40 doctors. If the truth was that there are only four who could actually see you, then this is false advertising. It is a form of treatment limitation that seems to be applied particularly to behavioral health much more than to primary care.

Here are five of the most common tricks used:

1. Mixing provider types in the directory, with no way to select out just one type. There may be 40 providers within 10 miles of your Zip code, but the psychologists, social workers, psychiatrists, psychiatric nurses, and counselors are all mixed in together, even though they each have different scopes of practice. This inflates the apparent size of the true network when only 6 of the 40 are psychiatrists.

2. Maintaining outdated information. These directories often have inaccurate addresses and phone numbers, even including providers who are retired or deceased. For example, Maryland law requires plans to update their online provider directories every 15 days, but it is obvious that this does not happen, nor is it adequately policed. There is no incentive to weed out stale information if it keeps the size of the network large and there are no financial penalties to having wrong information. A few years ago, the Maryland Psychological Association called more than 900 providers from 7 online insurance directories to determine whether they could see a patient in the insurance plan. Forty-four percent of the listed providers were unreachable based on the contact information in the directories.

3. Including providers who have stopped taking new patients. When providers stop accepting new patients with XYZ Insurance, they should either not be listed in the online directory or it should indicate that they are not taking new patients, as this otherwise makes the network look more adequate than it really is. The language that establishes state health benefit exchanges in the Affordable Care Act specifically requires that provider directories indicate which providers are actually able to accept new patients. This will require health plans to have a mechanism for providers to indicate when they are full or have stopped accepting patients with that insurance.

4. Long waiting lists. It is common to hear from patients who are frustrated in finding a psychiatrist in their directory because the ones who they are able to contact and who are accepting new patients, are booked up and cannot see them for many weeks, sometimes two to three months. This is surely a sign of an inadequate network.

5. Including hospital-based inpatient providers who do not have an outpatient practice. I am a hospital-based psychiatrist and do not have an outpatient practice. I participate with most insurance plans for inpatient treatment, but my five similar colleagues and I remain in these directories despite my attempts to get either de-listed or indicated that I don’t accept outpatients. Including all these inpatient physicians make the network look more robust than it is.
The Maryland Psychiatric Society has a referral service that gets more than a hundred calls per month looking for a psychiatrist. The executive director, Kery Hummel, tells me that most of these callers have been through their provider directory and have been unable to find anyone to see them in a timely manner.

Some of them are literally in tears over this frustration. My hospital department secretary, Dee Flythe, handles 180 of these calls every month, trying to help them find providers.

Finally, there is inadequate policing of network adequacy by state regulators, so this remains largely a complaint-driven oversight. But, according to our Insurance Administration, few patients make it to the point of calling the regulators to complain about the directories being inaccurate and inadequate. Some simple changes could increase the accuracy and transparency of their true network, such as:

• secret shoppers
• provider updatable directories
• links in the online directories that make it easy for frustrated patients to send complaints to regulators about inaccurate and misleading directory information
• claims-driven directories that indicate who is accepting new outpatients

This last change, connecting the provider directories with the claims database, would provide the transparency needed to show who is taking new outpatients. The health plan could show right next to each provider’s name the number of initial outpatient visit codes submitted over the most recently available period, say, 12 months. Those providers who have not recently taken any new patients for this health plan would indicate zero claims, so a potential patient could quickly find those who are taking new patients. Such an innovative and transparent mechanism also would make it obvious to regulators and purchasers if the network appears to be inadequate.

The problem now is that the plans have no incentive to expose the inadequacy of their network directories, while the regulators lack the staff to police them sufficiently. This nonquantitative treatment limit, in violation of the Parity Act, will continue until we have final regulations that specifically address network adequacy and that include consequences that are more costly than the financial benefit to having inadequate networks.

What can you do? Report inaccurate and inadequate networks to your state insurance commissioner, and ask patients to do the same thing. Speak up about this problem with legislators, regulators, and reporters. Shining some light on this widespread problem might help to reduce this loophole and hold plans accountable for making care accessible.

The irony is that patients with chronic medical problems who have untreated mental health and substance abuse problems cost the plans more money in claims. You’d think they would be bending over backward to improve this problem.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found at [email protected], and on the Shrink Rap blog.

I was invited to testify at a congressional forum last week by Congressman Chris Van Hollen about challenges in the implementation and enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA). Also present were Congressmen Jim Moran and Paul Tonko, and former Congressmen Patrick Kennedy and Jim Ramstad.  These dedicated representatives stayed past 9 p.m., reflecting their dedication and resolve to ensure that the Parity Act be fully implemented.

As most readers of Clinical Psychiatry News are aware, people with mental health and addiction problems have long been stigmatized and marginalized in the health care system, and this one action – passing the 2008 Parity Act – will prove to be a historic correction of this great wrong. Indeed, the first attempt to correct the discriminatory practices of the health insurance industry was passed in 1996, but the industry figured out how to get around the intent of that first Parity Act. The ongoing efforts to close these loopholes are currently stuck, with the lack of final regulations that would dictate to payers how MHPAEA will be implemented and enforced, despite the law being passed 4 years ago.

Even URAC, the standards-based accreditation organization that accredits health insurance plans, has beat the federal government by recently updating its standards to require health plans to clearly and effectively demonstrate compliance with the Parity Act. To my knowledge, this is the first organization to specifically build Parity Act compliance into its standards for accreditation.

There has been an interim final rule passed, but such temporary regulations lack the finality that makes health plans address the more challenging aspects of compliance, particularly the nonquantitative treatment limits, or NQTLs. One of the more pervasive, yet hidden, NQTLs is the inadequacy of behavioral health provider networks compared to that of primary care networks.

I believe that network adequacy is probably THE biggest barrier to accessing care for our patients. When I ask patients about any problems finding a primary care physician, they rarely have problems. But finding an in-network psychiatrist has become an overwhelming problem. The insurance plans do not maintain a large enough network of physicians who specialize in psychiatry, creating a bottleneck that makes it hard for patients to initiate treatment.

While there has been some reductions in the need to obtain prior authorizations for outpatient treatment, the loophole here is that if there are not enough psychiatrists in the network who can actually see the patients needing care, many patients go without. This effectively limits the number of claims a payer must pay out. This is a nonquantitative treatment limit that is more restrictive on the mental health and addictions side than on the physical health side.

You’d think that one could determine the adequacy of the network by the number of providers in it, but this number is not an accurate reflection of the true size of the network. Look more closely and you discover a number of tricks that inflate the apparent size of the network. Whether these “tricks” are intentional or not, they amount to – in my opinion – fraud. If you pay for a plan that has 40 doctors listed in its online provider directory, you expect that you can see most of these 40 doctors. If the truth was that there are only four who could actually see you, then this is false advertising. It is a form of treatment limitation that seems to be applied particularly to behavioral health much more than to primary care.

Here are five of the most common tricks used:

1. Mixing provider types in the directory, with no way to select out just one type. There may be 40 providers within 10 miles of your Zip code, but the psychologists, social workers, psychiatrists, psychiatric nurses, and counselors are all mixed in together, even though they each have different scopes of practice. This inflates the apparent size of the true network when only 6 of the 40 are psychiatrists.

2. Maintaining outdated information. These directories often have inaccurate addresses and phone numbers, even including providers who are retired or deceased. For example, Maryland law requires plans to update their online provider directories every 15 days, but it is obvious that this does not happen, nor is it adequately policed. There is no incentive to weed out stale information if it keeps the size of the network large and there are no financial penalties to having wrong information. A few years ago, the Maryland Psychological Association called more than 900 providers from 7 online insurance directories to determine whether they could see a patient in the insurance plan. Forty-four percent of the listed providers were unreachable based on the contact information in the directories.

3. Including providers who have stopped taking new patients. When providers stop accepting new patients with XYZ Insurance, they should either not be listed in the online directory or it should indicate that they are not taking new patients, as this otherwise makes the network look more adequate than it really is. The language that establishes state health benefit exchanges in the Affordable Care Act specifically requires that provider directories indicate which providers are actually able to accept new patients. This will require health plans to have a mechanism for providers to indicate when they are full or have stopped accepting patients with that insurance.

4. Long waiting lists. It is common to hear from patients who are frustrated in finding a psychiatrist in their directory because the ones who they are able to contact and who are accepting new patients, are booked up and cannot see them for many weeks, sometimes two to three months. This is surely a sign of an inadequate network.

5. Including hospital-based inpatient providers who do not have an outpatient practice. I am a hospital-based psychiatrist and do not have an outpatient practice. I participate with most insurance plans for inpatient treatment, but my five similar colleagues and I remain in these directories despite my attempts to get either de-listed or indicated that I don’t accept outpatients. Including all these inpatient physicians make the network look more robust than it is.
The Maryland Psychiatric Society has a referral service that gets more than a hundred calls per month looking for a psychiatrist. The executive director, Kery Hummel, tells me that most of these callers have been through their provider directory and have been unable to find anyone to see them in a timely manner.

Some of them are literally in tears over this frustration. My hospital department secretary, Dee Flythe, handles 180 of these calls every month, trying to help them find providers.

Finally, there is inadequate policing of network adequacy by state regulators, so this remains largely a complaint-driven oversight. But, according to our Insurance Administration, few patients make it to the point of calling the regulators to complain about the directories being inaccurate and inadequate. Some simple changes could increase the accuracy and transparency of their true network, such as:

• secret shoppers
• provider updatable directories
• links in the online directories that make it easy for frustrated patients to send complaints to regulators about inaccurate and misleading directory information
• claims-driven directories that indicate who is accepting new outpatients

This last change, connecting the provider directories with the claims database, would provide the transparency needed to show who is taking new outpatients. The health plan could show right next to each provider’s name the number of initial outpatient visit codes submitted over the most recently available period, say, 12 months. Those providers who have not recently taken any new patients for this health plan would indicate zero claims, so a potential patient could quickly find those who are taking new patients. Such an innovative and transparent mechanism also would make it obvious to regulators and purchasers if the network appears to be inadequate.

The problem now is that the plans have no incentive to expose the inadequacy of their network directories, while the regulators lack the staff to police them sufficiently. This nonquantitative treatment limit, in violation of the Parity Act, will continue until we have final regulations that specifically address network adequacy and that include consequences that are more costly than the financial benefit to having inadequate networks.

What can you do? Report inaccurate and inadequate networks to your state insurance commissioner, and ask patients to do the same thing. Speak up about this problem with legislators, regulators, and reporters. Shining some light on this widespread problem might help to reduce this loophole and hold plans accountable for making care accessible.

The irony is that patients with chronic medical problems who have untreated mental health and substance abuse problems cost the plans more money in claims. You’d think they would be bending over backward to improve this problem.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found at [email protected], and on the Shrink Rap blog.

I was invited to testify at a congressional forum last week by Congressman Chris Van Hollen about challenges in the implementation and enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA). Also present were Congressmen Jim Moran and Paul Tonko, and former Congressmen Patrick Kennedy and Jim Ramstad.  These dedicated representatives stayed past 9 p.m., reflecting their dedication and resolve to ensure that the Parity Act be fully implemented.

As most readers of Clinical Psychiatry News are aware, people with mental health and addiction problems have long been stigmatized and marginalized in the health care system, and this one action – passing the 2008 Parity Act – will prove to be a historic correction of this great wrong. Indeed, the first attempt to correct the discriminatory practices of the health insurance industry was passed in 1996, but the industry figured out how to get around the intent of that first Parity Act. The ongoing efforts to close these loopholes are currently stuck, with the lack of final regulations that would dictate to payers how MHPAEA will be implemented and enforced, despite the law being passed 4 years ago.

Even URAC, the standards-based accreditation organization that accredits health insurance plans, has beat the federal government by recently updating its standards to require health plans to clearly and effectively demonstrate compliance with the Parity Act. To my knowledge, this is the first organization to specifically build Parity Act compliance into its standards for accreditation.

There has been an interim final rule passed, but such temporary regulations lack the finality that makes health plans address the more challenging aspects of compliance, particularly the nonquantitative treatment limits, or NQTLs. One of the more pervasive, yet hidden, NQTLs is the inadequacy of behavioral health provider networks compared to that of primary care networks.

I believe that network adequacy is probably THE biggest barrier to accessing care for our patients. When I ask patients about any problems finding a primary care physician, they rarely have problems. But finding an in-network psychiatrist has become an overwhelming problem. The insurance plans do not maintain a large enough network of physicians who specialize in psychiatry, creating a bottleneck that makes it hard for patients to initiate treatment.

While there has been some reductions in the need to obtain prior authorizations for outpatient treatment, the loophole here is that if there are not enough psychiatrists in the network who can actually see the patients needing care, many patients go without. This effectively limits the number of claims a payer must pay out. This is a nonquantitative treatment limit that is more restrictive on the mental health and addictions side than on the physical health side.

You’d think that one could determine the adequacy of the network by the number of providers in it, but this number is not an accurate reflection of the true size of the network. Look more closely and you discover a number of tricks that inflate the apparent size of the network. Whether these “tricks” are intentional or not, they amount to – in my opinion – fraud. If you pay for a plan that has 40 doctors listed in its online provider directory, you expect that you can see most of these 40 doctors. If the truth was that there are only four who could actually see you, then this is false advertising. It is a form of treatment limitation that seems to be applied particularly to behavioral health much more than to primary care.

Here are five of the most common tricks used:

1. Mixing provider types in the directory, with no way to select out just one type. There may be 40 providers within 10 miles of your Zip code, but the psychologists, social workers, psychiatrists, psychiatric nurses, and counselors are all mixed in together, even though they each have different scopes of practice. This inflates the apparent size of the true network when only 6 of the 40 are psychiatrists.

2. Maintaining outdated information. These directories often have inaccurate addresses and phone numbers, even including providers who are retired or deceased. For example, Maryland law requires plans to update their online provider directories every 15 days, but it is obvious that this does not happen, nor is it adequately policed. There is no incentive to weed out stale information if it keeps the size of the network large and there are no financial penalties to having wrong information. A few years ago, the Maryland Psychological Association called more than 900 providers from 7 online insurance directories to determine whether they could see a patient in the insurance plan. Forty-four percent of the listed providers were unreachable based on the contact information in the directories.

3. Including providers who have stopped taking new patients. When providers stop accepting new patients with XYZ Insurance, they should either not be listed in the online directory or it should indicate that they are not taking new patients, as this otherwise makes the network look more adequate than it really is. The language that establishes state health benefit exchanges in the Affordable Care Act specifically requires that provider directories indicate which providers are actually able to accept new patients. This will require health plans to have a mechanism for providers to indicate when they are full or have stopped accepting patients with that insurance.

4. Long waiting lists. It is common to hear from patients who are frustrated in finding a psychiatrist in their directory because the ones who they are able to contact and who are accepting new patients, are booked up and cannot see them for many weeks, sometimes two to three months. This is surely a sign of an inadequate network.

5. Including hospital-based inpatient providers who do not have an outpatient practice. I am a hospital-based psychiatrist and do not have an outpatient practice. I participate with most insurance plans for inpatient treatment, but my five similar colleagues and I remain in these directories despite my attempts to get either de-listed or indicated that I don’t accept outpatients. Including all these inpatient physicians make the network look more robust than it is.
The Maryland Psychiatric Society has a referral service that gets more than a hundred calls per month looking for a psychiatrist. The executive director, Kery Hummel, tells me that most of these callers have been through their provider directory and have been unable to find anyone to see them in a timely manner.

Some of them are literally in tears over this frustration. My hospital department secretary, Dee Flythe, handles 180 of these calls every month, trying to help them find providers.

Finally, there is inadequate policing of network adequacy by state regulators, so this remains largely a complaint-driven oversight. But, according to our Insurance Administration, few patients make it to the point of calling the regulators to complain about the directories being inaccurate and inadequate. Some simple changes could increase the accuracy and transparency of their true network, such as:

• secret shoppers
• provider updatable directories
• links in the online directories that make it easy for frustrated patients to send complaints to regulators about inaccurate and misleading directory information
• claims-driven directories that indicate who is accepting new outpatients

This last change, connecting the provider directories with the claims database, would provide the transparency needed to show who is taking new outpatients. The health plan could show right next to each provider’s name the number of initial outpatient visit codes submitted over the most recently available period, say, 12 months. Those providers who have not recently taken any new patients for this health plan would indicate zero claims, so a potential patient could quickly find those who are taking new patients. Such an innovative and transparent mechanism also would make it obvious to regulators and purchasers if the network appears to be inadequate.

The problem now is that the plans have no incentive to expose the inadequacy of their network directories, while the regulators lack the staff to police them sufficiently. This nonquantitative treatment limit, in violation of the Parity Act, will continue until we have final regulations that specifically address network adequacy and that include consequences that are more costly than the financial benefit to having inadequate networks.

What can you do? Report inaccurate and inadequate networks to your state insurance commissioner, and ask patients to do the same thing. Speak up about this problem with legislators, regulators, and reporters. Shining some light on this widespread problem might help to reduce this loophole and hold plans accountable for making care accessible.

The irony is that patients with chronic medical problems who have untreated mental health and substance abuse problems cost the plans more money in claims. You’d think they would be bending over backward to improve this problem.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found at [email protected], and on the Shrink Rap blog.