A federal district court yesterday ruled that United Behavioral Health (UBH) must use medical necessity criteria and assessment tools developed by mental health and substance use disorder specialty organizations when making coverage-related determinations.
The ruling was part of a 10-year injunction against UBH issued by Judge Joseph Spero of the United States District Court for the Northern District of California in Wit v. United Behavioral Health. The injunction also includes a requirement that UBH personnel be trained in the use of the court-ordered medical necessity criteria and that UBH reprocess nearly 67,000 mental health and substance use disorder benefit claims over the next year. UBH is the country’s largest managed behavioral health care organization.
The injunction requires UBH to use the Level of Care Utilization System (LOCUS), Child and Adolescent Service Intensity Instrument (CASII), and Early Childhood Service Intensity Instrument (ECSII)—assessment tools developed by the American Association of Community Psychiatry (LOCUS) and the Academy of Child and Adolescent Psychiatry (CASII and ECSII)—as well as criteria developed by the American Society of Addiction Medicine.
Yesterday's ruling is the “remedy” phase of the case resulting from the court’s decision signed on February 28, 2019. The court held that UBH had illegally denied coverage for mental and substance use disorders based on flawed medical necessity criteria. Those denials impacted more than 50,000 UBH enrollees and involved 67,000 claims for coverage across four states: Connecticut, Illinois, Rhode Island, and Texas.
The ruling was the first time a major insurer was found to be relying on improper guidelines as a basis for denying health care services. In its 2019 decision, the court found that “[m]any mental health and substance use disorders are long term and chronic. While current symptoms are typically related to a patient’s chronic condition, it is generally accepted in the behavioral health community that effective treatment of individuals with mental health or substance use disorders is not limited to the alleviation of the current symptoms. Rather, effective treatment requires treatment of the chronic underlying condition as well.”
Reacting to the ruling, APA President Jeffrey Geller, M.D, M.P.H., said, “We applaud Judge Spero for holding this major insurer accountable for discriminating against patients with mental illness by denying them the care they need and are entitled to by law.”
He said APA will continue to be vigilant whenever insurers fail in their duty to abide by laws requiring parity between coverage of general medical care and coverage for mental illness and substance abuse disorders. “We hope insurers will take note of this ruling and stop the discriminatory practice of denying or limiting coverage of treatment for mental illness and substance use disorders.”
For further coverage of the Wit v. UBH decision, see upcoming editions of Psychiatric News. For background information, see the Psychiatric News article “UBH Internal Documents Show Focus on Short-Term Stabilization.”
(Image: iStock/DNY59)
APA Town Hall to Examine Generational Trauma of Structural Racism
APA President Jeffrey Geller, M.D., M.P.H., invites you to participate in the next of his series of town halls on structural racism throughout psychiatry. It will be held Monday, November 16, at 8 p.m. ET. Presenters will examine how the persistent stress of experiencing racial discrimination has an impact across generations and the degree to which the health consequences of racism and bigotry can be passed down from one generation to the next.
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