Today, NY State sent a letter to insurance companies, telling them they better comply with parity laws, and that they'll be checking up to make sure the insurers are keeping in line. Specifically, the letter was written to "remind" insurers that
MHPAEA (Mental Health Parity and Addiction Equity Act) prohibits issuers whose
policies or contracts provide medical and surgical benefits and MH/SUD benefits from applying
financial requirements, quantitative treatment limitations (“QTLs”), and NQTLs to MH/SUD
benefits that are more restrictive than the predominant financial requirements or treatment
limitations that are applied to substantially all medical and surgical benefits covered by the plan...
...state regulators [will] further review the processes, strategies, evidentiary standards, or other factors used inapplying the NQTL to both MH/SUD and medical and surgical benefits to determine parity compliance:
• preauthorization and pre-service notice requirements;
• fail-first protocols;
• probability of improvement requirements;
• written treatment plan requirement; and
• other requirements, such as patient non-compliance rules, residential treatment limits,
geographical limitations, and licensure requirements.
Accordingly, issuers are advised that the Department of Financial Services will be reviewing
issuers’ NQTLs and QTLs to ensure that issuers fully comply with MHPAEA and will take
necessary action in the event of any non-compliance.
Some additional NQTLs are:
"...treatment limitations based on geography, facility type, provider specialty, and the criteria limiting the scope or duration of benefits or services."
This is a good idea, enforcing rules for insurance companies. But I worry about certain bad ideas. In fact, I have a sneaking suspicion that insurance companies pay lawyers or others so inclined large sums of money to sit around all day and come up with new bad ideas by finding ways to comply with parity laws, but still hinder or delay reimbursement.
I've written previously about one of these bad ideas, namely, an insurance company's demand that I provide proof that my patient requires out of network services. I almost fell for this and started researching articles on continuity of treatment, etc., until Dinah from Shrink Rap pointed out that the insurance company doesn't need to cover out of network services, but if they do cover out of network, the patient doesn't need to justify not using in-network care.
Other egregious examples are stalling and finally informing the patient that the claims were never submitted, or that they were lost, and then sometimes even more egregiously, when the claims are resubmitted, the insurance company comes back and says it's too late to submit.
Or prior authorization. I tried to get Brintellix, now Trintellix (because Brintellix sounds too much like some other drug) approved, got rejected, appealed by filling out a long form that met every criterion for approval, got rejected again, and finally decided it's a crappy drug anyway, and not worth the effort.
A recent gem involved asking the patient's spouse, who is the primary insured, to call the insurance company to verify or "prove" that the patient has no other insurance (Doesn't, never did).
And I'm quite convinced that these stalling tactics are effective overall, because some percentage of them will not be pursued by patients. That percentage is a gold mine for insurance companies. And mental health patients are perhaps more susceptible than most to this hindrance, since things like depression, psychosis, and anxiety can get in the way of accomplishing tiresome, long, and frustrating tasks like talking to insurance companies.
Anyone else have insurance horror stories?