Those who go to bat with health insurers on behalf of their clients might need to take a closer look at how care standards are applied in coverage policies, according to attorney D. Brian Hufford, partner in the New York office of Zuckerman Spaeder LLP. Parity in the context of insurance coverage has many nuances, and advocates must be able to make a case for care based on clinical standards.
“Do a careful review on what kind of burden is imposed by insurance companies so you’re able to establish the necessary record when there are improper denials of coverage,” Hufford says.
Parity laws haven’t automatically made access to care easier. In fact, the rules are still being tested in court.
Zuckerman Spaeder filed a federal class action lawsuit May 21 against UnitedHealthcare Insurance Company and United Behavioral Health on behalf of plan members affected by mental health conditions or substance abuse disorders whose coverage was denied. The legal team believes United is not applying parity rules correctly in some situations and wants the insurer to resolve the current complaints and change its policy for the future.
“The key thing we’re seeking is injunctive relief,” Hufford says “We’re seeking to have United reprocess claims they denied in the past.”
Overly restrictive standards
He says there is very little precedent in mental health parity cases right now. The UnitedHealthcare suit, which was filed in California, calls into question the nonquantifiable restrictions of coverage, such as limits on the number of office visits the insurer would cover for a patient, or coverage for residential treatment for a patient with an eating disorder, for example.
He says United is using overly restrictive care standards as criteria for its coverage—inconsistent with nationally recognized scientific evidence, medical standards, and clinical guidelines—thereby, placing an undue burden on mental-health patients that wouldn’t be applied to patients with other medical conditions.
In some situations, patients were eligible for coverage for a certain level of care, but the insurer required “clear evidence” from the patient or the provider that the specific care was necessary. Without that evidence, care was denied. While insurers are looking to stretch the healthcare dollar as far as it will go, their utilization-management programs in this specific case do not reflect current care standards and place an unequal burden on mental-health patients, he says.
“If you have diabetes, we never see an insurer require clear and compelling evidence that you need care,” he says.
In the case, Zuckerman Spaeder’s argument says UnitedHealthcare is applying the wrong standards to residential care—using the acute inpatient standard rather than looking at the best level of care for the patient’s needs, Hufford says. The same applies to its standard for rehabilitation, in which, it is using withdrawal as the criteria for a patient entering inpatient rehab.
“In withdrawal, you need treatment for the medical condition of withdrawal. And then there is rehab, where you’re not in withdrawal, but need treatment to get sober to prevent sliding back,” he says. UnitedHealthcare, however, made withdrawal part of the criteria to cover rehab treatment. “But someone in rehab should not be in withdrawal,” he says.
Hufford says the suit seeks to uphold legal requirements that mental health conditions and substance abuse disorders are treated consistent with the treatment of other medical conditions. It details violations of the Mental Health Parity and Addiction Equity Act (Federal Parity Act) and the Employee Retirement Income Security Act (ERISA).