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Professional News
Psychiatrists Protest Blues' New Coverage Requirements
Psychiatric News
Volume 44 Number 23 page 22-39

Psychiatrists and the Illinois Psychiatric Society (IPS) are objecting to changes in the "behavioral" benefits coverage of the state's largest insurer that will require for the first time, for example, treatment authorizations for all patients.

The new requirements by Blue Cross and Blue Shield of Illinois (BCBSIL) are seen by some psychiatrists as ways to control costs and limit payments when the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (PL 110-343) goes into effect for the 2010 plan year. The law requires parity insurance coverage of treatment for mental illness, including substance abuse care.

"This [benefit change] will limit what we can do and what kind of care we can give to our patients," IPS President Lisa Rone, M.D., told Psychiatric News.

The insurer began notifying psychiatrists and mental health professionals in its network in early October that starting in January 2010 it will require all providers to obtain prior authorization for all new and existing patients. Treatment that is authorized after a phone request by the clinician will generally allow up to five treatment sessions, according to a company letter, but further treatment coverage would require submission of a clinical treatment plan.

The insurer's changes will "amount to limiting access and rationing care by virtue of the inconvenience factor," Rone said.

In response to a letter in mid-October from IPS outlining its concerns with the planned changes, BCBSIL officials said the policy is "being reformulated," but the company has declined to provide details on the new requirements or to say when they might be announced, said Meryl Sosa, IPS executive director, in an interview with Psychiatric News. The insurer also agreed to meet with IPS, but no date for the meeting has been set.

In response to questions from Psychiatric News, Mary Ann Schultz, senior manager of media relations for BCBSIL, said: "We're currently evaluating the rollout of the Outpatient Mental Health Management program in Illinois and will be sending more information to our Illinois providers."

Psychiatrists objected to the changes announced last month because they will require psychiatrists to request preapproval to treat prospective patients without any understanding of whether they have a mental illness or the type of disorder that might be present. Additionally, the requirement that providers call the insurer to make such requests—instead of e-mailing or faxing a form—could prove highly time consuming because psychiatrists might have to navigate an "onerous" automated calling system, Sosa said.

The new requirements would apply to psychiatrists who seek reimbursement from BCBSIL, regardless of whether they are in its provider network, according to Sosa.

No other insurers in the state have announced changes to their behavioral insurance plans recently, Sosa said.

"My guess is they are waiting to see how this plays out," she said

It remains unclear whether Health Care Service Corporation (HCSC), which owns BCBSIL and insurance companies in Oklahoma, New Mexico, and Texas, will implement the changes in states other than Illinois.

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BCBSIL is one of about 20 insurers nationwide that have proposed changes to their mental health care reimbursement policies effective in January, said Irvin "Sam" Muszynski, J.D., director of APA's Office of Healthcare Systems and Financing. However, the changes announced by other insurers are seen as less "onerous" than those of BCBSIL, he said. For instance, none would require preauthorization of subsequent sessions for existing patients.

The changes announced by insurers, according to mental health advocates, are in anticipation of increased utilization of mental health services that some insurers expect to result from the federal parity law.

"They know that the more administrative hassles you put up, the more you decrease [patient] visits" for some clinicians, Muszynski told Psychiatric News.

The new requirements come as federal regulators announced in early October that regulations implementing the federal parity law—which had been due in October—would not come until January at the earliest (Psychiatric News, November 20).

Insurers "held back, waiting to see whether we were going to get regulations," Muszynski said. "Now they're making their best guess."

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Insurers have blamed the uncertainty that ensued from the absence of regulations for not exempting psychiatrists and clinical psychologists from their new reimbursement procedures. APA requested such exemptions from several insurers that announced new rules on the basis of research showing that such requirements generally don't affect the quantity of services used by psychiatric patients. Insurers have concluded that such requirements limit the coverage requests of master's-level mental health professionals, according to Muszynski. Although insurers have long been able to set different reimbursement standards for different medical professionals based on determinations of medical necessity, for example, it is unclear whether different standards will be allowed under the federal parity law.

Insurers "read the parity law to mean that they can't treat [mental health professionals] differently," Muszynski said.

APA has questioned insurers' interpretations that the parity law both bars differing policies for different mental health clinicians while allowing differing policies for different physicians (psychiatrists and general practitioners, for example).

In a November 2 letter to the secretaries of the three federal departments that share oversight of the parity law, APA Medical Director James H. Scully Jr., M.D., urged regulations requiring equal application of the law to all clinicians.

Scully characterized insurance coverage that differs on the basis of who provides that care as a "violation of the law against discriminatory treatment limitations" included within parity.

The letter highlighted confusion around whether the federal parity law allows insurers to establish special requirements, such as a phone-in mandate on mental health clinicians, without similar requirements on the major providers of care for psychiatric illness: primary care physicians, who write most psychotropic prescriptions and who see patients for 80 percent of all mental health visits.

Less aggressive behavioral health coverage policy changes have been announced by the largest insurer in Florida, Blue Cross and Blue Shield of Florida (BCBSF). The company notified psychiatrists over the summer that they must notify BCBSF of all new patients on the first visit and to submit treatment plans after eight visits, which no other non-mental health specialists are required to do under the insurer's rules. Mental health clinicians also must submit for authorization the treatment plans of long-standing patients.

Psychiatrists in the state objected that mental health was singled out from other areas of medicine to endure new rules and that the goal was to reduce the demand for mental health care on the eve of parity's implementation. They also complained that the new requirements will place an enormous uncompensated new burden on them.

Some Florida psychiatrists responded by threatening to leave the insurer's network, according to Margo Adams, executive director of the Florida Psychiatric Society.

The Florida insurer is in discussion with psychiatrists and APA to simplify the requirements for progress notes and treatment plans and to allow psychiatrists to "pre-submit" those materials to prevent delays in treatment. APA also hopes to resolve questions such as whether the eight patient visits include those that occurred in the previous year and what copayments the insurer will require. blacksquare

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