Evidence of parity misdeeds starting to pile up

Although the mental health parity law went into effect in 2009, patients and providers are still fighting systemic inequity. A report this week on the television show “60 Minutes” documented several patients who needed longer-term inpatient care but were categorically denied that level of coverage by commercial insurers, sometimes resulting in distress leading to suicide. The show singled out giant national insurer Anthem and sparked more industry discussion about how parity is applied in practice.

In quantifying the denials, the show’s investigators found that among 11 authorization reviewers contracted by Anthem, the average denial rate was above 90%. One reviewer in particular, Timothy Jack, MD, was said to earn as much as $25,000 per month doing medical reviews for Anthem from his home and is well known by providers to deny coverage for intensive behavioral health services pretty much all the time.

I have some experience following the commercial health insurance industry, and I know from individual interviews with executives that typical denials in the physical health space are nowhere near the 90% range. The Affordable Care Act provides consumers the opportunity to appeal if they want a coverage denial reviewed by a third party, and those disputes for physical health tend to result in approvals about 50% of the time.

Imagine if an insurer denied coverage of 90% of advanced cancer treatments or refused to pay for neonatal intensive care for a newborn, insisting that the baby could be stepped down to the regular nursery for care. Every politician in Washington would attack.

In fact, Patrick Kennedy reacted to the “60 Minutes” segment in a statement this week, expressing outrage over the denials and saying, “There have been at least 10 lawsuits filed over violations of state and federal parity law in the last three years alone.  Fines have been assessed by state regulators as well.”

On behalf of one of the patients introduced in the show, Lisa S. Kantor, partner at Kantor and Kantor Law, is arguing the case in a class action suit filed against Anthem.

"The treatment team—the psychiatrists, the dieticians and psychologists—are the ones who know what is best for the patient. Historically and to date, the insurance companies and their doctors often send patients home too soon, when they still need supervision and specialized care,” Kantor said in a press release.

It’s worth watching the “60 Minutes” report if you didn’t see it.

Examining standards

I also talked to attorney D. Brian Hufford, partner in the New York office of Zuckerman Spaeder LLP who is working on a separate class action suit against United Behavioral Health. He says United is using overly restrictive care standards as criteria for its coverage—inconsistent with nationally recognized scientific evidence, medical standards and clinical guidelines. For example, United is using withdrawal as the criteria for inpatient rehab treatment when in reality rehab patients shouldn’t be in withdrawal.

Hufford told me via email that the United case has survived a motion to dismiss, allowing the firm to move forward with the discovery phase. In early December, a new, parallel case was filed related to outpatient care, stating that United is “improperly restricting the scope of their insurance coverage for outpatient mental health and substance abuse treatment.”

Read more about the United Behavioral Health inpatient case here.