Patients get cash back in ValueOptions parity settlement

A parity settlement in New York has Beacon Health Options paying a $900,000 penalty and reworking its review process for behavioral health claims. It’s significant because the company previously known as ValueOptions administers behavioral health benefits for 2.7 million New Yorkers and 45 million consumers nationwide.

By forcing Beacon/ValueOptions to comply with parity laws, a large population of insured individuals will now have confirmation that their behavioral benefit coverage is on par with their physical health benefits. Even though a state parity law passed in New York in 2006 and a national parity law passed in 2008, enforcement is an ongoing issue.

Four times the denials

According to the settlement announcement, an investigation by the N.Y. Attorney General’s Health Care Bureau found that ValueOptions consistently issued denials twice as often for behavioral claims and four times as often for addiction recovery services, when compared to other physical health services.

 “Insurance claims for mental health care should be treated just the same as insurance claims for physical healthcare, and my office will continue to ensure full compliance with our state’s mental health parity laws,” said Attorney General Schneiderman in the announcement. “The millions of New Yorkers who need mental health and addiction services should never feel shame or stigmatized and my office will remain committed to eliminating barriers to patients getting the care they need.”

Last year, the Attorney General also entered into settlements with two major New York health insurers, MVP Health Care and EmblemHealth, both of which use Beacon Health Options/ValueOptions as a vendor for administering behavioral health benefits. The settlements require extensive reforms in claims management procedures and force the company to charge the lower, primary care co-payment for most outpatient visits to mental health and substance use disorder treatment providers. Additionally, the settlement now requires the benefit company to cover residential treatment.

Beacon Health Options also has obligations to submit previously denied MVP and Emblem mental health and substance use disorder treatment claims to an independent appeal process, which could result in millions of dollars being returned to members wrongfully denied benefits.

Already, through the ongoing appeals process for MVP, $250,000 in previously denied claims have been overturned and will be going back to members who paid out of pocket.

The details

According to the announcement, Beacon Health Options/ValueOptions has agreed to overhaul its behavioral health benefits process by:

• Removing visit limits for almost all behavioral health services, and removing preauthorization requirements for outpatient behavioral health services.

• Covering services provided by mental health practitioners, such as Mental Health Counselors, licensed under Article 163 of the New York Education Law.

• Ensuring that its provider networks and online provider directory are accurate, and assisting members in transitioning providers where necessary.

• Conducting full and fair reviews for services that require preauthorization, such as inpatient substance use disorder treatment.

• Providing detailed oral and written explanations for denied claims, so that members can exercise their appeal rights, and providing up-to-date information about alternative treatment providers.

• Classifying claims correctly so that reviews are done expeditiously and members are afforded full appeal rights.

• Removing the requirement that members “fail” outpatient substance use disorder treatment before qualifying for inpatient rehabilitation treatment.

• Basing the number of treatment days or visits approved on members’ needs, rather than arbitrary limits.

• Integrating medical and behavioral health claims review staff, which will facilitate the coordination of members’ care.

• Continuing coverage of treatment pending the completion of appeals, so that treatment is not interrupted.

• Reimbursing coverage of treatment for most diagnoses listed in the Diagnostic and Statistical Manual of the American Psychiatric Association (the “DSM”), including gender identity disorders.

• Reimbursing members for out-of-network services at the usual, customary and reasonable rate (“UCR”) for the relevant behavioral health service, without applying arbitrarily applying lowered rates for non-M.D. providers.

• ValueOptions will also post parity disclosures on its website, file regular compliance reports with the Attorney General, and pay a $900,000 penalty.