Pursuing violators seen as way to achieving mental health parity

 

NEW YORK – The Mental Health Parity and Addiction Equity Act, passed in 2008 and strengthened within the Affordable Care Act, continues to be routinely violated, but there are avenues for complaint that can help keep pressure on third-party payers, according to an update on this topic presented at the annual meeting of the American Psychiatric Association.

“There are basically two approaches: One is the top-down approach, which is actual government enforcement; the other is the bottom-up approach, which is to work through the courts with class action suits,” reported Daniel Knoepflmacher, MD, assistant professor of clinical psychiatry at Cornell University, New York.

Under the law, third-party payers must provide mental health services at parity to other types of medical or surgical services. Some loopholes used to deny mental health coverage were closed in the Affordable Care Act, but Dr. Knoepflmacher contended that denial of mental health services continues to be a common problem.

Some of the enforcement falls to the Employment Benefits Security Administration (EBSA), which is an agency within the Department of Labor. EBSA, which recently published a report on mental health parity violations spanning 2016-2017, steps in because health insurance is commonly an employee benefit, Dr. Knoepflmacher explained.

In the EBSA report, 136 mental health parity violations were documented, said Dr. Knoepflmacher, who summarized the findings. These were not single denials of coverage but 136 cases of insurance company policy violations that covered thousands or even hundreds of thousands of participants.

For example, one denial of coverage occurred for chronic behavioral disorders. This is a violation of parity, because there are no such restrictions on coverage of chronic physical disorders. In another example, coverage of mental health disorders was provided only when a treatment plan had been submitted.

“Requiring a treatment plan is one of the ways often used to create more onerous requirements for mental health or substance use providers,” Dr. Knoepflmacher said. “What makes this a parity violation is that there is no equivalent restriction for providing medical or surgical benefits.”

 

Both of these examples, which were found in insurance plans each covering about 300,000 individuals, represented nonquantitative treatment limitations, which Dr. Knoepflmacher said are often more difficult to identify than quantitative limitations, such as a cap on patient consultations or access to medications.

Another example of a nonquantitative limitation is low reimbursement when different types of services make parity difficult to establish. Recently, a firm that evaluates employee benefits compared the reimbursement received by psychiatrists with that received by primary care physicians for CPT code 99213 claims. This is a code applied for behavioral assessment. Based on national data, the report found that primary care clinicians received a 20% higher reimbursement on average than did mental health specialists. The disparity was greatest in Connecticut, and Nebraska was the only state offering similar reimbursement. In all other states, psychiatrists received less.

“This is an apples-to-apples comparison,” Dr. Knoepflmacher said. “What does this difference create? This leads to a reality that is familiar to many of us, which is that a large number of psychiatrists are working out of network.”

This is highly relevant to parity for mental health services: Reduced numbers of mental health specialists working in network mean patients face greater barriers to finding a clinician at an affordable cost.

 

EBSA provides a hotline (866-444-3722) for reporting parity violations. It also provides information on its website for steps to take when violations occur, Dr. Knoepflmacher said. However, Dr. Knoepflmacher conceded that establishing parity is a moving target because third-party payers alter policies and use their own criteria to establish which mental health services represent necessary care.

“Most psychiatrists I have spoken to have experienced some sort of denial of coverage,” Dr. Knoepflmacher noted. Not all may be a violation of parity, but Dr. Knoepflmacher suggested that psychiatrists should be proactive in order to preserve mental health and substance use services for those who need them.

 

NEW YORK – The Mental Health Parity and Addiction Equity Act, passed in 2008 and strengthened within the Affordable Care Act, continues to be routinely violated, but there are avenues for complaint that can help keep pressure on third-party payers, according to an update on this topic presented at the annual meeting of the American Psychiatric Association.

“There are basically two approaches: One is the top-down approach, which is actual government enforcement; the other is the bottom-up approach, which is to work through the courts with class action suits,” reported Daniel Knoepflmacher, MD, assistant professor of clinical psychiatry at Cornell University, New York.

Under the law, third-party payers must provide mental health services at parity to other types of medical or surgical services. Some loopholes used to deny mental health coverage were closed in the Affordable Care Act, but Dr. Knoepflmacher contended that denial of mental health services continues to be a common problem.

Some of the enforcement falls to the Employment Benefits Security Administration (EBSA), which is an agency within the Department of Labor. EBSA, which recently published a report on mental health parity violations spanning 2016-2017, steps in because health insurance is commonly an employee benefit, Dr. Knoepflmacher explained.

In the EBSA report, 136 mental health parity violations were documented, said Dr. Knoepflmacher, who summarized the findings. These were not single denials of coverage but 136 cases of insurance company policy violations that covered thousands or even hundreds of thousands of participants.

For example, one denial of coverage occurred for chronic behavioral disorders. This is a violation of parity, because there are no such restrictions on coverage of chronic physical disorders. In another example, coverage of mental health disorders was provided only when a treatment plan had been submitted.

“Requiring a treatment plan is one of the ways often used to create more onerous requirements for mental health or substance use providers,” Dr. Knoepflmacher said. “What makes this a parity violation is that there is no equivalent restriction for providing medical or surgical benefits.”

 

Both of these examples, which were found in insurance plans each covering about 300,000 individuals, represented nonquantitative treatment limitations, which Dr. Knoepflmacher said are often more difficult to identify than quantitative limitations, such as a cap on patient consultations or access to medications.

Another example of a nonquantitative limitation is low reimbursement when different types of services make parity difficult to establish. Recently, a firm that evaluates employee benefits compared the reimbursement received by psychiatrists with that received by primary care physicians for CPT code 99213 claims. This is a code applied for behavioral assessment. Based on national data, the report found that primary care clinicians received a 20% higher reimbursement on average than did mental health specialists. The disparity was greatest in Connecticut, and Nebraska was the only state offering similar reimbursement. In all other states, psychiatrists received less.

“This is an apples-to-apples comparison,” Dr. Knoepflmacher said. “What does this difference create? This leads to a reality that is familiar to many of us, which is that a large number of psychiatrists are working out of network.”

This is highly relevant to parity for mental health services: Reduced numbers of mental health specialists working in network mean patients face greater barriers to finding a clinician at an affordable cost.

 

EBSA provides a hotline (866-444-3722) for reporting parity violations. It also provides information on its website for steps to take when violations occur, Dr. Knoepflmacher said. However, Dr. Knoepflmacher conceded that establishing parity is a moving target because third-party payers alter policies and use their own criteria to establish which mental health services represent necessary care.

“Most psychiatrists I have spoken to have experienced some sort of denial of coverage,” Dr. Knoepflmacher noted. Not all may be a violation of parity, but Dr. Knoepflmacher suggested that psychiatrists should be proactive in order to preserve mental health and substance use services for those who need them.

 

NEW YORK – The Mental Health Parity and Addiction Equity Act, passed in 2008 and strengthened within the Affordable Care Act, continues to be routinely violated, but there are avenues for complaint that can help keep pressure on third-party payers, according to an update on this topic presented at the annual meeting of the American Psychiatric Association.

“There are basically two approaches: One is the top-down approach, which is actual government enforcement; the other is the bottom-up approach, which is to work through the courts with class action suits,” reported Daniel Knoepflmacher, MD, assistant professor of clinical psychiatry at Cornell University, New York.

Under the law, third-party payers must provide mental health services at parity to other types of medical or surgical services. Some loopholes used to deny mental health coverage were closed in the Affordable Care Act, but Dr. Knoepflmacher contended that denial of mental health services continues to be a common problem.

Some of the enforcement falls to the Employment Benefits Security Administration (EBSA), which is an agency within the Department of Labor. EBSA, which recently published a report on mental health parity violations spanning 2016-2017, steps in because health insurance is commonly an employee benefit, Dr. Knoepflmacher explained.

In the EBSA report, 136 mental health parity violations were documented, said Dr. Knoepflmacher, who summarized the findings. These were not single denials of coverage but 136 cases of insurance company policy violations that covered thousands or even hundreds of thousands of participants.

For example, one denial of coverage occurred for chronic behavioral disorders. This is a violation of parity, because there are no such restrictions on coverage of chronic physical disorders. In another example, coverage of mental health disorders was provided only when a treatment plan had been submitted.

“Requiring a treatment plan is one of the ways often used to create more onerous requirements for mental health or substance use providers,” Dr. Knoepflmacher said. “What makes this a parity violation is that there is no equivalent restriction for providing medical or surgical benefits.”

 

Both of these examples, which were found in insurance plans each covering about 300,000 individuals, represented nonquantitative treatment limitations, which Dr. Knoepflmacher said are often more difficult to identify than quantitative limitations, such as a cap on patient consultations or access to medications.

Another example of a nonquantitative limitation is low reimbursement when different types of services make parity difficult to establish. Recently, a firm that evaluates employee benefits compared the reimbursement received by psychiatrists with that received by primary care physicians for CPT code 99213 claims. This is a code applied for behavioral assessment. Based on national data, the report found that primary care clinicians received a 20% higher reimbursement on average than did mental health specialists. The disparity was greatest in Connecticut, and Nebraska was the only state offering similar reimbursement. In all other states, psychiatrists received less.

“This is an apples-to-apples comparison,” Dr. Knoepflmacher said. “What does this difference create? This leads to a reality that is familiar to many of us, which is that a large number of psychiatrists are working out of network.”

This is highly relevant to parity for mental health services: Reduced numbers of mental health specialists working in network mean patients face greater barriers to finding a clinician at an affordable cost.

 

EBSA provides a hotline (866-444-3722) for reporting parity violations. It also provides information on its website for steps to take when violations occur, Dr. Knoepflmacher said. However, Dr. Knoepflmacher conceded that establishing parity is a moving target because third-party payers alter policies and use their own criteria to establish which mental health services represent necessary care.

“Most psychiatrists I have spoken to have experienced some sort of denial of coverage,” Dr. Knoepflmacher noted. Not all may be a violation of parity, but Dr. Knoepflmacher suggested that psychiatrists should be proactive in order to preserve mental health and substance use services for those who need them.