New Hampshire Investigates Handling of SUD Treatment Claims
Abstract
The market-conduct reports of three companies in the state, which will be followed by a broader look at compliance with the federal parity law, revealed how state oversight can be critical to enforcement.
Coverage of treatment for substance use disorder (SUD) and handling of claims for SUD treatment by major insurers in New Hampshire is satisfactory in some ways—but could stand improvement in others.
That was the finding of “market-conduct” examinations of three large insurers—Anthem, Cigna, and Harvard Pilgrim—by the New Hampshire State Insurance Department (NHID). The department undertook the exams in November 2015 in response to the state’s opioid crisis; providers and patients around the state had pointed to coverage denials and red tape as barriers to addiction treatment, according to the department.
Importantly, the department next plans to look more broadly at compliance with the federal parity law by insurers in the state, especially policies regarding nonquantitative treatment limits (NQTLs), such as provider reimbursement rates.
The biggest areas of deficiency for all carriers involved their websites—specifically, a consumer’s ability to easily navigate the sites to access accurate information about in-network providers, as well as to obtain copies of the medical management policies and procedures that guide the companies’ decisions about coverage. The NHID has required corrective action to address these problems.
The other strong concern revealed in the reports involves Harvard Pilgrim’s oversight of United Behavioral Health/Optum—a separate company that handles all behavioral health services for Harvard Pilgrim, including coverage for SUD services—as well as Harvard Pilgrim’s delays in providing claims handling information (approved/denied rates) in a format that would allow comparison between the three companies being examined. The NHID is planning a follow-up study of UBH/Optum’s practices to include looking at whether its uniform requirement of prior authorization for behavioral health services is compliant with mental health parity requirements.
In other areas, companies were found to be performing well or according to standards. For instance, the department found that protocols used by companies to review SUD claims for medical necessity were generally appropriate, as were procedures for handling appeals and grievances.
In some instances, the exams themselves brought about change. During the 2015 exam period, for example, insurance companies faced a shortage of SUD providers in some parts of the state. In response to examiners’ requests that they outline steps they were taking to address the shortages, companies expanded their networks as more providers became available, putting them in a better position to respond to increased demand for behavioral health services, which have been more broadly covered under private insurance in recent years due to federal requirements under the Affordable Care Act.
Irvin “Sam” Muszynski, J.D., the director of Parity Implementation and Enforcement Policy at APA, told Psychiatric News that the insurance department report shows that state oversight of insurers is critical to enforcement of parity with regard to treatment for substance use disorders.
“The report demonstrates that oversight can ensure that patients are treated fairly by insurers,” he said. “The NHDI report also reveals shortcomings that are not confined to New Hampshire—poor or confusing information about substance use treatment on insurer websites and thin or inadequate networks of providers. We think the department’s investigation into parity compliance, especially regarding nonquantitative aspects such as provider rates, will be revealing.”
In a statement, New Hampshire Insurance Commissioner Roger Sevigny said release of the exam reports was “an important step in our ongoing effort to remove obstacles to behavioral health services for [state residents] with private insurance coverage.” He added, “The reports give us a baseline understanding of insurance companies’ practices as we work to ensure that they comply with the law, especially with respect to mental health parity and network adequacy.”
Once the NHID has sufficient data to compare the companies’ approval/denial rates, examiners plan to take a more in-depth look at mental health parity compliance for all carriers, including for the 2016 and 2017 plans in which members of the Premium Assistance Program are enrolled. This will also include a look at provider reimbursement rates and fee schedules, which the reports address on a preliminary basis. ■
The individual market-conduct reports for each company, along with information about how to read the reports and an overview of the reports, can be accessed here.
