Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Wednesday, July 27, 2016

Good and Bad Ideas

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?


  1. Dinah of Shrink Rap here. I have a new one for you. Got a letter from the parent of a patient I've seen all year: insurance is rejecting my claim because they can't prove I'm licensed, could I give them a new claim form with my licensing information? I sent a new claim form for them to resubmit, but there is no place on the standardized HCFA 1500 form (which I give to patients at every appointment) for my license info, just my NPI which is automatically in the boxes. I wrote back to the parent with my license number, but I do believe any one can just google my state licensing board, click on 'verify a license' and I'm the only doc with my name in the state.

  2. Prescriptions usually fall into a different category of insurance craziness. Getting a newer psych med preauthorized is the same hassle as getting a newer "medical" med preauthorized and tends to take about the same amount of back and forth and back and forth between the doctor and the patient and the insurance and the pharmacy. There doesn't tend to be a real difference between "medical" and "psychiatric" when it comes to prescriptions, though overall the preathorization system is frustrating and difficult. Similar to out of network claims - they actually tend to not get lost and there isn't much stalling - it's all computerized, even on my measly city government insurance. The claims actually tend to be processed in about a month and are only returned if the statement is handwritten - the computer system cannot always accurately read the handwriting. That is the only time in 9 years of treatment that I've had a claim returned and the representatives have always politely and uniformly explained that it's due to the handwriting, to resubmit it.

  3. And Dinah, insurance companies often request that the psychiatrist/psychologist/social worker send in their own license information before they will process the claim. If they have recently switched computer systems it also happens. It is indeed an absurd request and requirement since it's information readily available, but they insist that the practitioner does it. I've tried to circumvent the system - because of fear of practitioners like you who become so annoyed over taking all of a one time three minutes to give the information to the insurance directly (and yes, I have had providers provide that info; they uniformly report that it took less than five minutes and was not a big deal at all) - by providing it to the insurance company myself, but they will not accept it. It has to come from the practitioner. Yep, it's absurd and silly, but so is most bureaucracy, and it's your patient who's losing out, so be gracious. It is not your patient's fault, and it is those claims that make it possible for him or her to pay your fees.

  4. This, on the other hand, is something that I have not seen psychiatric meds manufacturers pull, or even try to, even with newer medications.