Court Ruling Against UBH Provides Roadmap for Fighting Insurance Denials

Psychiatrists spending precious time battling health insurance companies over coverage denials should familiarize themselves with the class-action suit David Wit, et al., v. United Behavioral Health (UBH). Gleaning a few crucial lessons from this important ruling could alter the outcome of those routinely frustrating phone calls with insurers.

On March 5, the United States District Court for the Northern District of California issued liability findings against UBH, one of the nation’s largest behavioral health insurers (Psychiatric News). The decision, issued by Judge Joseph C. Spero, described how internally developed medical necessity guidelines employed by UBH were inconsistent with generally accepted standards of care articulated by various professional associations (including APA, the American Academy of Child and Adolescent Psychiatry, the American Society of Addiction Medicine, and the American Association of Community Psychiatrists), the Centers for Medicare and Medicaid Services, peer-reviewed research, and expert consensus.

In his decision, Judge Spero highlighted eight generally accepted standards of behavioral health care for patient placement and treatment intensity selection. Any insurance guidelines failing to adhere to these are deficient. Highlighted below are several of the core principles, using direct quotations in bold from the written decision. Hopefully, psychiatrists can reference them in discussions with insurers whose coverage determinations are believed to be inconsistent with generally accepted standards of care.

• “It is a generally accepted standard of care that effective treatment requires treatment of the individual’s underlying condition and is not limited to alleviation of the individual’s current symptoms.” A denial of care in the absence of acute symptoms not only fails to address the ongoing effects of the underlying condition, it also increases the likelihood of deterioration and threatens the long-term functioning of the affected individual. 

• “It is a generally accepted standard of care that effective treatment of mental health and substance use disorders includes services needed to maintain functioning or prevent deterioration.” Once again, a central goal of treatment should be the preservation of function and prevention of relapse.

• “It is a generally accepted standard of care that effective treatment requires treatment of co-occurring behavioral health disorders and/or medical conditions in a coordinated manner that considers the interactions of the disorders and conditions and their implications for determining the appropriate level of care.” This standard highlights the real-life complexity of psychiatric patients, who often have comorbid diagnoses that necessitate more intensive, long-term treatment to improve function and quality of life.

• “It is a generally accepted standard of care that patients should receive treatment for mental health and substance use disorders at the least intensive and restrictive level of care that is safe and effective.” While this principle highlights that treatment should generally not be more intense or restrictive than necessary, Judge Spero also clarified that “placement in a less restrictive environment is appropriate only if it is likely to be safe and just as effective as treatment at a higher level of care in addressing a patient’s overall condition, including underlying and co-occurring conditions.”

• “It is a generally accepted standard of care that when there is ambiguity as to the appropriate level of care, the practitioner should err on the side of caution by placing the patient in a higher level of care.” As most clinicians can attest, external pressure from insurers typically goes in the opposite direction, using coverage limitations to push for less intensive treatment at patient expense.

• “It is a generally accepted standard of care that the appropriate duration of treatment for behavioral health disorders is based on the individual needs of the patient; there is no specific limit on the duration of such treatment.” When acting in good faith, clinicians and patients should have the most accurate perspective on what length of treatment is necessary to treat specific problems. A predetermined, one-size-fits-all approach that insurers use to limit the duration of treatments cannot meet the clinical needs of every patient.

The principles outlined in Judge Spero’s decision provide a clear, easy framework for showing how clinically indicated treatments meet generally accepted standards of care. Now, by referencing these principles, psychiatrists can approach utilization reviews with more confidence, backing up their arguments with a strong legal precedent.

As the wider fight for behavioral health parity continues, stay tuned for the next phase of Wit v. UBH, when Judge Spero will determine legal remedies to address the deficiencies in UBH’s medical necessity guidelines and the wrongful denials stemming from their use. ■