Forbes: How Consumers, Providers Can Report Managed Care Abuses

NYAPRS Note: Consumers and providers are busily preparing for New York’s transfer of fee for service behavioral health services into Medicaid managed care plans. In only a month, NYAPRS’ Executive Seminar will feature a strong program providing timely information in a variety of areas, including panels and presentations like:

  • From Policy to Implementation: A View from the State
  • Update on Medicaid/Medicare, Managed Long Term Care and Community First Choice Initiatives
  • Systems Transformation in the Era of Healthcare and Budget Reforms
  • Innovations in Integrated Care: A National Perspective
  • New Partnerships: Behavioral and Medical Health Innovations
  • Addictions Treatment and Recovery Services under Managed Care
  • Finding the Opportunities in Healthcare Reform: The Inside Track
  • Managed Care Financed Innovations
  • Preparing Clinic Programs for Managed Care
  • Grounding Multicultural Competencies in Healthcare Reform Initiatives

Register today for NYAPRS April 25-6 Annual Executive Seminar at; see program schedule at!


How Consumers And Providers Can Report Abuses By Managed Mental Health Care Companies

By Todd Essign Forbes March 26, 2013

Managed mental health-care companies are a mess now that federal law has made it illegal for them to discriminate against people with a mental illness. How could they be otherwise? They make money by denying care to those who need it, and that is now illegal. Clearly, as far as business models go, this one should be in trouble.

But yet, they’re doing OK. How come? Managed mental health care is continuing to make money in part because consumers and providers are caught in webs of helplessness so tight employers, who purchase the coverage, do not know what is going on. However, once people start standing up for what’s right, the model will crumble, benefitting both patients and the employers who’s money buys the coverage.

Managed mental health care companies count on the fact that helpless resignation really seems like the best of all possible responses to the decisions they make: patients fear exposing their vulnerabilities to their employers; providers get caught by apathy, and fears of reprisal. Not everyone has the courage to pursue legal action like the plaintiffs in therecent class action filed against UnitedHealth Groupalleging, among other things, that United was systematically “undermining access to treatment.”

I am personally no stranger to insurance company induced helplessness, the heavy sluggish weight that descends while being told a standard, empirically-grounded treatment is not consistent with “national standards” and no further appeal is possible for the “adverse care determination.” From the other side I’ve seen patients become fearful and helplessly hopeless after being told treatment they knew to be life-saving was officially deemed “not medically necessary.”

Afterwriting about the class action against UnitedI learned about an alternative to the stark choice of either helpless resignation or courageous legal action. I did not know this previously, but patients and providers can report a company’s potentially illegal actions directly to theDepartment of Labor. And while, as I also learned, there are several complexities—like this applying only to employer plans with more than 50 employees—the process is doable.

For the last week I’ve had an e-correspondence withMeiram Bendat, both a psychoanalyst and a lawyer who is one of the plaintiff attorneys in theUnitedHealth Group class action. He’s also founder ofPsych-Appealand self-described “persona non grata” with insurance companies. He helped me understand that the DOL web-site allows reports of violations of federal parity laws. As you may know parity laws mandate insurance companies to behave towards mental illness claims as they do towards medical/surgical claims.

I want to be clear that filing a complaint on the DOL web-site titled “Request for Assistance from The Department of Labor, EBSA” (EBSA is the Employee Benefits Security Administration) can seem daunting. But, as I discerned from Mr. Bendat, if you keep the following three points in mind you can make it work.

1. Completing the Form

First, you need to know that in response to “You are requesting assistance with:” one should tick: “Plan is not complying with legal requirements (such as ERISA, COBRA, HIPAA, the Affordable Care Act).” If you can get and include copies of your “Summary Plan Description” or “Certificate of Coverage” booklet (both of which you are entitled to have) all the better.

2. “Medical Necessity” Determinations

It is important to understand the relationship between “medical necessity” and the parity laws your insurance plan may be violating. You see, companies whose business it is to deny care to those who need it are very smart about how they do it. They keep their bad actions well hidden, but not so well hidden that you can’t find them if you know where to look.

The DOL does not get involved in the content of medical necessity determinations. They are not interested in people complaining about “adverse care determinations.” Rather, they care about the process. They want to know whether or not the process of determining medical necessity for a mental illness is the same as that used for a medical/surgical problem. It is a violation of federal parity laws for a company to use a different standard for determining medical necessity when it is a mental illness than when they are doing so for medical/surgical care.

A crucial question is whether or not the company uses national standards of care for determining medical necessity for medical/surgical claims while using their own internal standards for determining medical necessity for mental illness. In other words, have they stacked the deck or not?

For example, andsomething about which I have previously written, consider Major Depressive Disorder. The American Psychiatric Association has published treatment guidelines for this illness. It states:

This document represents a synthesis of current scientific knowledge and rational clinical practice regarding the treatment of patients with major depressive disorder.

viaPsychiatryOnline | APA Practice Guidelines | Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition.

However,United developed their own internal guidelinesthat are significantly different—and far more restrictive—than the national standards. In fact, United’s so-called standards stack the deck so that those who most need care can be denied care.

So, should one be filing such a complaint with the DOL, it is important to clearly specify that the insurance company in question was using internal standards for determining medical necessity for mental illnesses while they used national standards for medical/surgical problems. It is not enough just to say it was an unfair determination.

3. Pre-certification (the oxymoron of “Prospective Review”)

Another reason to file a complaint with the DOL would be if your plan requires pre-certification of outpatient psychotherapy but does not require pre-certification for a routine outpatient medical visit.I must admit I have gotten so used to having these “reviews” conducted before anything happens that it took me awhile to appreciate the oxymoronic absurdity of reviewing something before it happens. But not only is it absurd, it may also be a violation of federal parity laws if it is a procedure only employed for mental illness claims and not medical/surgical claims.