Federal judge orders nation's largest insurer to use independent rules, pay for more treatment
Social isolation is strongly linked to poor mental health, so it makes sense that mental health issues are soaring amidst the ongoing COVID-19 pandemic. Access to behavior health services has historically been more difficult than it should be. The World Health Organization found prior to the pandemic, countries were spending less than 2% of their national health budgets on mental health, and struggling to meet their populations’ needs.
A federal judge recently shed some hope for more mental health treatment by ordering UnitedHealth Group to use independent rules that will lead the nation’s largest insurer to pay for more treatment and pave the way for more challenges to health insurers’ ability to set their own guidelines for what treatment is medically necessary.
UnitedHealth had been using their own “overly restrictive guidelines” to deny mental health and substance use treatment. Now, they must reprocess 67,000 claims they denied for 50,000 people from 2011 to 2017, and for the next decade must decide claims using independent guidelines developed by professional mental health associations instead of their own internal guidelines.
UnitedHealth must apply new standards created by professional groups including the American Society of Addiction Medicine and the American Association of Community Psychiatrists.
This court order follows the court’s 2019 decision that United Behavioral Health violated its own insurance plan by using “overly restrictive guidelines” that denied services which would be covered had the insurer used “generally accepted standards” to judge the claims. The judge wrote that the company’s guidelines allowed them to only cover treatment that stabilized the patient “while ignoring the effective treatment of members’ underlying conditions.”
The move to mental health parity has been slow-going and years in the making. The Mental Health Parity and Addiction Equity Act of 2008 aims to block insurers from hindering access to behavioral health, and the Affordable Care Act also included provisions to enhance coverage.
Though both laws are a decade old, insurers have found ways around the requirements, and state and federal oversight of access has been limited. Plaintiffs in the suit against UnitedHealth said they were often denied care as soon as they were deemed “stable,” though behavioral healthcare often requires long-term care management.
Experts are hopeful that these court decisions will put payers on notice and encourage mental health providers to reclaim their authority over standards instead of surrendering to insurance companies—especially at this critical time when behavior health services are needed more than ever before.
Quadax is committed to staying on top of payer changes. Our comprehensive, up-to-date library of claim processing rules and edits are updated bi-weekly by our Edits & Documentation Group (EDG). The Quadax EDG team of experts, who are knowledgeable in both billing and ANSI claim requirements, reference nationally recognized sources, including AMA, CPT guidelines, Medicare Physician Fee and more.
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