Rules put forth by BlueCross BlueShield of Vermont (BCBS/Vermont) requiring prior authorization and setting reimbursement rates for psychiatrists below those for primary care physicians violate the Mental Health Parity and Addiction Equity Act of 2008, according to APA and Vermont Psychiatric Association (VPA) officials. The law requires that health plans provide mental health benefits at parity with other medical benefits.
Separate treatment limitations are a violation of the law, said James H. Scully Jr., M.D., then APA’s CEO and medical director, and Margaret Bolton, M.D., VPA president, in a letter to the insurer.
As of last spring, BCBS/Vermont permitted patients 10 mental health visits without prior authorization but required preauthorization for any visits beyond that number.
“We are not aware of any clinically appropriate standards of care that would permit BCBS to ration services in this manner,” said Scully and Bolton.
In addition, BCBS/Vermont violates the federal parity law by paying primary care physicians more than psychiatrists when billing for the same CPT codes and providing similar services, APA and VPA noted. The practice also harms patients, since it discourages treatment by the physicians who specialize in mental health and discourages network participation by psychiatrists.
The problems have existed for years but came to the fore when BCBS/Vermont created a new company—Vermont Collaborative Care—to manage mental health benefits in the state, said Bolton in an interview. In addition, APA officials have been looking more closely in all states for potential parity violations.
Others see deeper forces at work.
“BCBS just doesn’t value what psychiatrists do,” said Alice Silverman, M.D., past president of the VPA, in an interview with Psychiatric News. “As a result, mental health care in Vermont has become a two-tier system. Wealthy patients can pay out of pocket, but working people who depend on their insurance have limited access to psychiatric care.”
Worse yet, the burdens of preauthorization coupled with lower reimbursements make early career psychiatrists leery of practicing in the state, she said.
After the initial exchange of letters failed to clarify matters for psychiatrists, the two sides held a face-to-face meeting October 2 in Montpelier, Vt. Results of the meeting were mixed, at best, said Colleen Coyle, J.D., APA general counsel.
“BCBS agreed that in-network psychiatrists no longer needed prior authorization for evaluation and management or for evaluation and managements plus psychotherapy in the same session,” she said. “But if they do only psychotherapy, they still need prior authorization. The process makes no sense.”
Furthermore, members are reporting that the changes did not apply to out-of-network psychiatrists or to any other mental health care providers, said Coyle. This amounts to a “treatment limitation” that also violates the parity act.
The insurer agreed to review overall preauthorization requirements, said Bolton. “We will advocate that preauthorization requirements be dropped for all psychiatrists in Vermont, in or out of network.”
However, BCBS/Vermont’s responses to the lack of reimbursement parity between primary care providers and psychiatrists were not satisfactory, said Coyle.
“We argued that mentally ill patients were better off being seen by psychiatrists, given their specialized training, yet the insurer will pay a primary care physician more for the visit,” she said. “BCBS/Vermont agreed to look at it.”
Splitting care between a primary care physician and a psychologist would require two separate office visits and be more costly to patients as well, imposing undue burden and expense on mental health patients.
Negotiations will continue with the insurer, said Coyle. “We’re making some progress, and I’m guardedly optimistic.”
Bolton agreed and said she will actively maintain contacts with Vermont Collaborative Care and with BCBS to resolve remaining differences. ■