United Healthcare mental health suit that they lost... what should we do?

[MikeR861723]

I've been seeing a therapist for 2 years now on weekly 1 hour visits.  Previously we had bc/bs ad they processed the claims for 1 hour visits - CPT 90837.

Changed to United Healthcare this year and they are denying the claims for the 1 hour visits as not medically necessary.  changing to 45 minute visits with CPT 90834, they process those. 

As I wondered - who are they to decide medical necessity -  a federal court agreed.  UHC lost a class action related to this

https://www.modernhealthcare.com/law-regulation/united-loses-court-behavioral-health-coverage-rules

But there is still a phase of the case to determine the remedy, THEN UHC will likely appeal.

I wonder - do we still do 45 minute sessions and likely have no basis to appeals / benefit from new rules (can you say 'I would have done 1 hour visits, if I knew they were covered')

or 

do 1 hour visits, pay all out of pocket on the hope in the end they will be deemed accepted and UHC covers the visits?

thanks!

Mike

[somarco]

The case cited appears to revolve around MHP as well as what kind of practitioner will be covered under the plan.

Mental health care is an area of claim management that is open to abuse by providers and patients. In the age of managed care, determining and defining medical necessity is often subjective.

This particular litigation is still ongoing and may not be finalized for years. The plaintiff "won" in phase 1 as decided by a court located in an area of the country where cases are notoriously favorable to the plaintiff.

If your claim is honored by UHC when submitted as a 45 minute session my suggestion is to have your therapist continue to bill under the referenced CPT-4 code and move on.

Or you can fight the carrier in hopes of a "win" which may never happen.

The choice is yours. 

[MikeR861723]

Thanks!  Yeah, just do 45 and move on I guess.  and taking years still for it to play out! Soooooo true : (

Fortunately I can afford the treatment.  In one of the articles about this, they talked of a kid that United stopped paying for his substance abuse in-patient care.  Family took him out and he died soon after. Not sure of the cause of death - OD, but I remember the movie John Q and glad but surprised that doesn't happen in the real world.

[somarco]

I have been in the health insurance business for over 45 years. Most of the time the carrier gets it right (claims) but there are also some gray areas.

Even when the carrier is right the insured doesn't always agree.

But many, probably most, never bother to read their SPD or policy until a claim is denied.

That is the WRONG time to learn about your coverage.

Over the year, working with literally thousands of clients, I can honestly say I have never seen a legitimate claim denied. At the same time I have seen claims handled extra-contractually that never should have been paid.

If a client has a legitimate beef I will go to bat for them. Most of the time the claim is settled in a matter of days.

Some issues are worth fighting, some are not.

The introduction of ICD10 coding created a LOT of situations where the provider has considerable lattitude in how to code the claim. Providers are even trained in ways to gerrymander the system for maximum reimbursement.

It is much easier for the provider and patient to work WITHIN the system vs trying to fight for a change.

YMMV

[MikeR861723]

Thanks!  I do agree with you that people should know what they are buying / getting.

But realistically, that doesn't happen much these days as all the info you could read grows into encyclopedia length.  Not an excuse, just realism.

a couple questions - have you heard about that court case concerning United Healthcare?  People's claims were correctly turned down according to the policies. but the policies were 'wrong' / illegal / etc. (like all the info you can read going into a purchase of something, i didn't read all 126 pags of the judge's ruling in this case : ) 

There was even a section that I did read where the court said that people appealed denials and were denied again... because the company was applying the same wrong / illegal criteria.

[somarco]

I have not followed nor have I dissected the referenced court case. My general opinion of class action suits is the attorney makes more than the defendents. Plaintiffs are rounded up under the guise of "you and many others have been wronged now we will make the company pay".

On more than one occasion I have received payouts from class action suits just because I purchased a product at one time. In every case I was given the chance to opt out and file my grievance as an individual or take the payout. Doing nothing resulted in a check that followed months later. I don't recall ever getting more than $20.

Seems a lot of hype but it does line the pockets of the attorneys.

Individual suits are generally more productive and tend to make the news vs class action. Companies seem to modify their actions when a big payout to an individual makes headlines. Not so much for class action.

Don't take this next comment as flippant. If a carrier is willing to cover treatment for a 45 minute session but not for 60 minutes, where is the damage? I have a family member that is a mental health counselor. The practice where they work is very good at knowing which carriers are lenient and which are not when it comes to claims. They know how to work the system to make sure they are paid.

People in general like to complain about insurance coverage but it becomes more personal when your ox is the one being gored.

Every state requires policies to be written in plain language. Benefit summaries are generally laid out in such a way as to make it clear when a carrier will pay for a particular claim and when they will not.

But your issue seems to be primarily with claim adjudication which is outside the realm of policy language. The adjudication process is administrative, not contractual. This is true with any type of insurance.

Generall accepted practice for health claims start with medical necessity and then progress to what is the most cost effective treatment. What I have read regarding MH claims and UHC seems to be more along the lines of this. UHC limits reimbursement for specific claims where other carriers may be more liberal.

Limited payout is not, in my opinion, a judicial issue as long as the guideline is followed equally for all claims of that nature. In this situation it does not appear that MHP rules are violated. Rather, UHC is deciding which claims and providers will be paid. That is their prerogative as long as claims with the same CPT code are paid equally across all covered participants.

Managed care is not a one-size-fits-all process.

Back to your observation that the policies were "wrong" or "illegal", I must have missed that. The plaintiffs can certainly allege that but that does not make it so. And in this case, as I pointed out earlier, the UHC situation is administrative adjudication, not contractual. It does not appear the claims are being denied because the condition treated is wrongly or illegally excluded. Rather the managed care side of the benefit is limiting the payout for specific treatment.

If UHC were violating MHP rules this would, in my opinion, be a bigger issue. But what I have read does not seem to support a MHP wrongdoing.

Hope this helps.

[MikeR861723]

Funny, this was in the paper today: )

That seems like a trick question - What's the damage with them paying for a 45 min session not 60?  Uh, 15 min of additional therapy? 

There's ways to get paid but there's a point when they are staying ethical / legal, there's a point they don't understandably cross.  

You said:

If UHC were violating MHP rules this would, in my opinion, be a bigger issue

I think that's exactly the situation. From the court ruling (the judge's decision):

https://s3.amazonaws.com/assets.fiercemarkets.net/public/004-Healthcare/united_behavioral_health.pdf  

on page 93:

183. First, the very fact that the Guidelines were riddled with requirements that provided
for narrower coverage than is consistent with generally accepted standards of care gives rise to a
strong inference that UBH’s financial interests interfered with the Guideline development process.

on page 104:

203. Applying the standard of review discussed above, and based on the Findings of
Fact related to the challenged Guidelines and UBH’s Guideline development process, the Court
finds, by a preponderance of the evidence, that UBH has breached its fiduciary duty by violating
its duty of loyalty, its duty of due care, and its duty to comply with plan terms by adopting
Guidelines that are unreasonable and do not reflect generally accepted standards of care

page 111:

211. One condition of coverage under each class member’s Plan was that the services
for which coverage was requested are consistent with generally accepted standards of care and/or
the standards mandated by state law. In applying its Guidelines to class members’ requests for coverage, UBH was interpreting the terms of their Plans.

page: 106:

213. In addition to plan terms requiring UBH to use generally accepted standards of
care, UBH was specifically required, pursuant to the laws of Illinois, Connecticut, Rhode Island,
and Texas, to administer requests for benefits pursuant to Plans governed by those states’ laws in
accordance with those laws. For the reasons stated above, the Court finds that UBH did not
adhere to these state law requirements.

and others, but I have ADD, so I start to nod off at the length of the document.  And yes, I am picking certain paragraphs, potentially missing other things. But the articles about the case talked about United acting illegally.

I'm not following your last paragraphs, but basically, from what I got in the articles /  findings of the court - United created policies on what proceedures they would / wouldn't reimburse.  They did that more with their own financial health in mind than the patient's health while they werre supposed to be using a medically necessary level in their policies.  They did that to be able to offer lower premiums / get more people to sign up and still make a profit.  Kind of a bait and switch?

That's how my wife's company signed up.  the existing insurance that did cover my 1 hour visits had a higher premium this year.  United/ oxford was lower... and doesn't cover my 1 hour visits.

This is not like wanting to buy a acura at a honda price.  both insurers have to cover medically necessary treatments / standards of care.  United didn't cover medically necessary treatments. 

Like buying the same grade of gas at 2 different places..  'regular' gas has a certain oxtane.  That station sells it for 10c less.  But it's still regular gas.  They are more efficient?  They have lower costs?  Whatever reason, you are still getting regular gas.  Health insurance covers medically necessary treatments for things that aren't excluded.  If they include that medical issue, then they need to follow generally accepted levels of care and the costs involved.

WSJ 3-28-19

[GailL1]

@MikeR861723 

What sort of UHC coverage do you have ? 

Employer based coverage? Whether self-insured (ERISA) or regular employer type?

Medicare ?  Medicare Advantage?

The reason I ask is that the suit appears to be only for those with private or workplace coverage.

Under Medicare type plans, like Advantage plans, Medicare would have more to say about the situation. You would file an appeal with Medicare.

Medicare and Your Mental Health Benefits

(see page 21 - Appeals)

Depending upon the size and nature of the employer type plan - some states even have specifics which they must follow.

You also need to know your plans guidelines for mental health - specifically behaviorial type.  Even if mental health is now on parity with other type health conditions - there is a certain expectation that a condition will improve - this is especially true of behaviorial type mental conditions.

There is no way I can advise you on your specific questions - Are you even sure that the lawsuit covers your situation?

The reason I ask is that the suit appears to be only for those with private or workplace coverage.

Under Medicare type plans, like Advantage plans, Medicare would have more to say about the situation. You would file an appeal with Medicare.

Medicare and Your Mental Health Benefits

(see page 21 - Appeals)

[MikeR861723]

We have insurance through my wife's job / employer provided but not self funded.  We.'re in our late 50s.

I thought ERISA dealt with all private insurance plans provided by private employers?

Does the lawsuit cover my situation?  Likely not specifically. But it touches on the idea that United is overly strict on mental health criteria / don't follow unbiased recommendations but rather look to be overly restrictive to not have to pay out as much.