Thursday, January 6, 2011
Blue Cross retreats on preapproval for mental health
services
Health
professionals, Illinois insurance director had fought plan
By Bruce Japsen, Tribune reporter
8:16 p.m. CST, January 5, 2011
Amid intense fire from health
professionals and the Illinois insurance director, Blue Cross and Blue Shield
of Illinois has dropped a plan to require subscribers to get prior approval to
access a broad range of outpatient mental health services.
The state's largest health insurance
company started requiring preauthorization for patients under its preferred
provider organization, or PPO, plans in recent weeks.
Illinois Blue Cross on Wednesday
would not disclose how many of its health plan members use outpatient
behavioral health plan services but said the policy was limited to its PPO
plans, which are the most popular choice sold by the company. Illinois Blue
Cross has 6.7 million health plan members.
"This would have served as a
subtle deterrent to getting care," said Paul Pendler, a clinical
psychologist in private practice in Chicago. "Anytime you put limits or a
requirement to precertify for access to services brings a higher likelihood
that people will say, 'Forget it,' and not get treatment."
Health insurance companies have been
trying to control rising health care costs as their pool of insured customers
dwindles amid persistent high unemployment and as more Americans drop their
medical care coverage. The health care overhaul law, which will bring subsidies
for 30 million Americans to buy health benefits, does not kick in for another
three years.
Insurance companies say they
generally institute preauthorization so they can begin a process of managing a
patient's medical care.
In an internal Illinois Blue Cross
memo obtained by the Tribune that was sent to mental health providers, the
insurer said the intent of its preauthorization program was "to improve
coordination of care between medical and behavioral health care providers."
In addition, the preapproval was
intended to give health plan members "guidance regarding care options and
available services based on their benefit plan" and to help
"indentify co-existing medical and behavioral health conditions
earlier."
But mental health professionals say
preauthorization in this case violates federal law under the Mental Health
Parity and Addiction Equality Act, which is designed to make mental health
services no different than other medical services. Mental health coverage is
not mandated, but the law requires such benefits be equal if offered by an
employer.
Typically, a person in a PPO with,
say, a sore knee does not have to call an insurance company to get
preauthorization to see a primary care professional, even if the pain does not
go away and the patient needs additional counseling, a prescription or
treatment.
Complaints over the preapproval plan
drew the attention of Illinois Insurance Director Michael McRaith, whose staff
has been meeting with Illinois Blue Cross in recent weeks. Among those
criticizing the insurer were hundreds of health professionals from the Illinois
Psychiatric Society and the Illinois Psychological Association.
"The Department of Insurance is
committed to the principle set forth in (the mental health parity law) that
coverage for mental health or substance-use disorder benefits must be
equivalent to coverage for other benefits," McRaith said Wednesday.
"In the event that ambiguity is argued to exist in the implementation (of
the law) or its regulations, the department will resolve such ambiguity in
favor of the patients and families for whom the law is meant to protect."
McRaith said the state is continuing
to monitor mental health management practices in the insurance industry.
Medical care providers say it makes
little sense to curtail usage of outpatient mental health services that can be
preventive and save health care dollars in the long run.
"Consumers pay $50 to $10 to
nothing for visits that are about $100," said Pendler, the clinical
psychologist. "In today's health care, there is no value in managing the
least expensive service. It's something that is costing $100 a pop, which is
nickels in the bucket when you think of people getting well from such care and
reducing the likelihood of all sorts of more expensive" care.
Illinois Blue Cross will continue to
require preauthorization for certain services, such as "behavioral health
partial hospitalization, intensive outpatient programs at facilities, all
outpatient electroconvulsive therapy and psychological and neuropsychological
testing," said Dr. Scott Sarran, the insurer's chief medical officer. bjapsen@tribune.com
