Most people in our industry know what the Mental Health Parity and Addiction Equity Act (MHPAEA) is, and those who are not aware will probably look at you as if you have five heads! It can be a complex topic, but nonetheless, an important one. In short, “parity” was enacted to make sure there was fairness between mental health and/or substance use disorder (MH/SUD) benefits and medical and/or surgical benefits that are covered by health insurance. The law was enacted in 2008 and does not require a plan to offer MH/SUD benefits; however, if the plan does offer these benefits, it must offer the same benefits as the other medical and surgical benefits it covers. An example of a parity requirement is the frequency of office visits. Under this law, patients are not limited to medically necessary appointments. Under plans that require equal benefits that follow Parity, you can’t limit a patient’s number of office visits for counseling sessions, just as you wouldn’t limit the number of emergency room visits or any other major medical care.
Every treatment center, psychologist, psychiatrist, case manager and counselor should be aware of what this law is and the violations that can occur. The end goal is to work with insurance companies, not report violations and make more work for ourselves. We are already inundated with paperwork and clients to treat. This begs the question, “How do we work together and not against each other?” Here is the bottom line: 1 in 4 people will develop a mental disorder in their lifetime and many of those same people suffer from co-occurring disorders like alcoholism and drug abuse. Patients need access to treatment and they shouldn’t have to suffer at the hands of a faceless insurance representative on the other line telling them what is or isn’t clinically appropriate for them. Of course, I do understand the insurance criteria which needs to make sure that tests and services are “medically necessary” as there are a few bad apples who take advantage of insurance upcoding. This occurs across the entire medical field and not just in the substance use and mental health arena.
Violations and coverage denial should not be commonplace against all treatment centers. Lately, we have seen insurance companies decide to go rogue and stop paying all claims due to “audits.” It’s becoming a big concern amongst patients as well. Treatment centers need to be able to use their cash flow and sustain their business so they can continue to treat patients. By imposing these audits, treatment centers cannot get reimbursed the insurance money that is owed to them. They are left with major problems and essentially have to turn down patients since their insurance cannot be utilized. This then becomes a public health concern.
Are you denied higher levels of care like Residential treatment
(RES) or Partial Hospitalization (PHP) because the patient hasn’t already “failed at a lower level of care first?” Are you limited to so many psychiatry sessions per year? Have you been required to obtain pre-authorization for outpatient services? These may be Parity violations.
So what do we do? Here is a link which is a good resource that lists the common violations: www.paritytrack.org/know-your-rights/common-violations
When reporting violations, have your call center document the time, name of insurance representative and what the violation seems to be. It’s always a best practice to record every phone call for accuracy, making sure both parties are aware the call is being recorded.
If the insurance is a state governed plan issued here in Florida, you need to contact the Department of Insurance (www.floir.com). You are encouraged to call the Consumer Helpline 877-693-5236. They prefer to speak with the consumer (patient) since it is a health related issue and even having a Power of Attorney (POA) doesn’t matter. They want to hear it from the patient and they will look into the denial and compare it to what the policy states.
If the plan is governed by federal law –you need to contact CMS and the Department of Health and Human Services in your state.
Allison Seriani is Public Relations and Communications for Destination Hope, Inc.