Is Your Insurer Denying Your Loved One Mental Health Care? Try These Four Tips

Is Your Insurer Denying Your Loved One Mental Health Care? Try These Four Tips

Although the Affordable Care Act made mental health care and addiction treatment far more accessible to Americans than it previously had been, insurers still can be slow to understand your loved one is in crisis and needs care.

For example, many communities lack sufficient numbers of mental health professionals and/or mental health beds. Thus, wait times to see a mental health professional can be outrageously long – several months even, particularly for those who are on Medicare or Medicaid as opposed to private insurance. But even for those insured with the nation’s major carriers, it can take 30 days or longer in some places to get in to see a provider. Unless – and it’s important to remember there usually is always an unless – it’s considered an emergency.

In an eye-opening viewpoint published recently in JAMA Psychiatry, Susan M. Essock of Columbia University Department of Psychiatry, New York, explains how to slash through the red tape.

Essock is particularly well qualified for her piece on how to be a red-tape ripper. That’s because she negotiated contracts for insurers from the day managed behavioral health care organizations (MBHOs) came into existence in the early 1990s.

“In 1990, one of the nation’s largest employers, IBM Corporation, became the first major U.S. employer to ‘carve out’ its mental health benefit by contracting with an MBHO,” she writes in the JAMA piece. “The IBM-MBHO contact was so newsworthy that its announcement made page 1 of the business section of the July 27, 1990, Wall Street Journal. The article began, ‘International Business Machines Corp. named a small health care company to handle its mental health program, reflecting corporate America’s search for ways to contain spiraling psychiatric costs.'”

Essock sat on the board overseeing the quality of mental health care provided to IBM employees for two decades.

If you’re banging your head against the wall trying to get your loved one proper mental health treatment under your employer’s coverage, here are four takeaways from Essock’s piece broken down into plain English.

1. Commit to being your loved one’s advocate. For people with a mental health disorder and/or a substance abuse problem, navigating the health care system can be overwhelming. Just as caregivers for the elderly soon learn their loved one can’t do it without them, those advocating for people with mental illness have just as big a task ahead.

2. Form a solid relationship with your employer’s benefits manager and turn to them for help when needed. If you believe your loved one needs to see a mental health professional immediately as opposed to next week, go to HR and talk to the benefits manager. According to Essock, MBHO contracts “likely includes language about being able to access appropriate health care professionals within certain time parameters (e.g., two weeks for routine appointments, 48 hours for urgent issues), including such contractual exceptions in beneficiaries’ benefit overviews that would help patients and their families know what to push for.”

3. When your MBHO makes a decision you don’t agree with, appeal it. This often occurs when a loved one is hospitalized. An MBHO may want to send a patient home even when they still are hearing voices telling them to do things. “Appeals are rare and handled quickly, especially when vendors are responsible for charges incurred during appeals. The (advocate) may also reach out to alert her employer’s benefits manager that the MBHO appears to be pushing for a speedier discharge than seems appropriate and/or discharge without a follow-up plan. Benefits managers know what vendors are obligated to do and have leverage if a vendor appears to be encouraging/tolerating inadequate care.”

4. Closely monitor your loved one’s situation. Are they getting better? If not, sometimes there are issues with “problematic yesses,” as Essock puts it. “Most managed care contracts are not just about managing money; they also call for spotting clinically risky situations and offering alternatives. These include situations where clinicians may inadvertently be helping people be ill (e.g. helping someone ‘recover’ false memories of abuse) and outpatient care that seems diffuse and unending. I have seen outpatient treatment plans that, years into treatment, say essentially, ‘I am this patient’s only friend, so she needs to keep seeing me.’ Managed behavioral health care organizations’ utilization reviews should flag such care as questionable and intervene because payers are paying for clinical oversight to make sure that clinical-service quality is at least minimally acceptable.”

This may be true in a majority of cases, but also remember that a mother, a father, a spouse, a sibling, or a loved one probably knows the patient better than any algorithm. If you believe your loved one has improved markedly with a certain therapist, advocate that they continue to see that therapist even if a computer program says otherwise. People with mental health issues often have experienced a range of trauma. To throw someone who is improving back into trauma by switching providers defeats the purpose of mental health care and could jeopardize a recovering alcoholic and/or addict’s sobriety.


Sources

1. Essock, Susan. (2016, November). What to Do When the Managed Care Firm Says No. JAMA Psychiatry. Retrieved Dec. 6, 2016, from http://jamanetwork.com/journals/jamapsychiatry/fullarticle/2552798

Written by David Heitz