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