Managed care organizations must use medical necessity criteria and assessment tools developed by nonprofit mental health and substance use disorder specialty organizations when making coverage-related determinations.
That’s what APA and seven other medical organizations told the United States Court of Appeals for the Ninth Circuit in a friend-of-the-court brief filed yesterday in the case David Wit, et. al., v. United Behavioral Health (UBH). The brief is informed by a 2020 APA Position Statement on Level of Care Criteria for Acute Psychiatric Treatment.
UBH is appealing an October 2020 ruling by Judge Joseph Spero of the United States District Court for the Northern District of California ordering the company to re-process more than 67,000 claims for mental health and substance use disorder (MH/SUD) treatment, using level of care and clinical guidelines developed by nonprofit mental health and substance use disorder associations. Spero’s injunction followed a 2019 ruling by the same court that UBH had illegally denied those claims based on flawed medical necessity criteria.
The 2019 ruling and the 2020 injunction are groundbreaking because managed care companies have traditionally created their own guidelines for level of care and medical necessity, factoring costs into the coverage decisions. “Such guidelines may lead to denial of coverage for treatment that is recommended by a patient’s physician and even cut off coverage when treatment is already being delivered,” according to the APA brief.
In the brief, APA outlined eight requirements for coverage decisions derived from guidelines developed by APA, the American Society of Addiction Medicine, and other mental health specialty groups:
- Practitioners must undertake a multidimensional assessment prior to designing a treatment plan.
- Effective MH/SUD treatment requires addressing underlying conditions, not merely presenting symptoms.
- Proper treatment of MH/SUDs requires coordinated treatment of co-occurring conditions.
- Patients should be placed in the least-restrictive level of care that is both safe and effective.
- When the proper level of care is ambiguous, physicians should exercise caution and place the patient in the higher level of care.
- Effective MH/SUD treatment often requires providing continuing services to support recovery and prevent relapse or deterioration.
- Duration of care should be individualized and not subject to arbitrary limits.
- Treatment plans for children and adolescents must account for their unique needs.
“Standards of care should be based on the best treatment for patients, not the bottom line,” APA President Vivian Pender, M.D., said in an APA news release. “Some managed care organizations develop their own coverage guidelines that are overly focused on stabilizing acute symptoms of mental health and substance use disorders, rather than treating the underlying illness. When the injury is physical, insurers treat the underlying disease and not just the symptoms. Discrimination against patients with mental illness must end.”
APA CEO and Medical Director Saul Levin, M.D., M.P.A., noted that failure to provide appropriate levels of care for treatment of patients with mental illness and/or substance use disorders can lead to relapse, overdose, transmission of infectious diseases, and death. “APA calls upon courts, legislatures, and insurance commissioners to require insurance companies to deliver the care for which patients and employers have paid based upon evidence-based, objective, and patient-centered guidelines, rather than company profits.”
For related information, see the Psychiatric News article “UBH Ruling Called an Enormous Victory for Patients, Wake-Up Call to Insurers.”
Serve Your Association and Make a Difference
Members of the Board of Trustees make the important decisions that ultimately steer the organization and have a real-life impact on patients. To reflect APA’s diversity, members of minority or underrepresented groups are especially encouraged to run for office. Nominate yourself or a colleague for the following national offices for 2022: president-elect, treasurer, trustee-at-large, Area 3 and 6 trustees, and resident-fellow member trustee-elect. The deadline for nominations is Wednesday, September 1.
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