The fight for insurance coverage for behavioral and substance abuse care has been ongoing for decades. Several federal laws and regulations have been enacted to provide parity in coverage between physical and mental health care. While insurance companies can no longer charge higher copays or deductibles or set annual or lifetime upper limits on mental health care, recent lawsuits demonstrate that inequities still exist. These actions against insurers like United Health Behavioral, Health Care Service Corp., Aetna and others claim they are imposing restrictive standards of medical necessity to deny coverage for these services. Insurance companies argue they are using clinical standards, but some contend the data and standards to measure mental health care are far behind those used for medical care. In any event, more suits are likely as mental health awareness increases and patients and their families turn to mental health professionals and lawyers to support their cases.
A recent ruling in California is a good example. A class action representing 50,000 plaintiffs was brought again UnitedHealth Group’s United Behavioral Health (UBH), the nation’s largest behavioral health insurer challenging its discriminatory treatment of behavioral health claims. The important ruling in Wit, et. al. v. UnitedHealthcare et. al. and Alexander, et al. v. United Behavioral Health found that UBH’s treatment guidelines were far more restrictive than generally accepted standards for mental health and substance abuse treatment. The criteria were skewed toward covering short-term “acute” treatment, while disregarding chronic or complex mental health conditions that often require ongoing care. Expert witnesses in the case criticized the criteria the insurer used for deciding what care was medically necessary, paying only to stabilize a patient’s condition, not to improve their underlying illness.
There are standard criteria for mental health and substance abuse treatment coverage by groups such as the American Society of Addiction Medicine, which experts argue insurers must adopt to ensure equal treatment of behavioral health conditions. Some insurers contend they do use such criteria. Nonetheless, a recent article from the nonprofit Kaiser Health News details numerous studies showing the growing gap in coverage of mental health care particularly when it involves hospital care. The insurance industry’s own data compiled in the 2017 Health Care Cost and Utilization Report illustrates the significant increase in out of pocket spending for those needing mental health services.
The stigma of mental health problems already discourages many to seek help, but the high cost of care and lack of insurance coverage make it even more difficult. Experts from the Journal of the American Medical Association, Substance Abuse and Mental Health Services Administration and National Institute of Mental Health have studied the rise in mental health issues and the need for proper care.
For attorneys who are considering litigating one of these cases, experts witnesses are an important part of establishing whether insurers are utilizing or applying appropriate standards for deciding coverage. An experienced Board-Certified Psychiatric expert from a top university medical center is an invaluable asset in such matters.
To find a highly qualified Psychiatric expert to assist in your case, contact Elite Medical Experts.