The federal government has been supportive of the behavioral health treatment field in establishing rules implementing the Mental Health Parity and Addiction Equity Act. It’s the follow-through that is the challenge.
Establishing federal rules was just the beginning for implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA). “The federal Department of Labor and others in the federal government have told us on numerous occasions that we can bring them appeals and complaints, that they’re willing to take a look at them,” said Mark J. Covall, president and CEO of the National Association of Psychiatric Health Systems (NAPHS). “But to be honest, we’re having a difficult time getting complaints and appeals that are specific enough for the government to act on them.”
There are two key reasons why the specificity isn’t there. One is that in mental health and addiction, the referral source is the managed care organization. Whereas in medical/surgical care settings, the physician is the primary referral source, in behavioral healthcare settings, the critical business relationships, that is, referrals, are with managed care organizations are “critical business relationships. Covall adds, “Upsetting that business relationship isn’t something most providers want to do.”
The other reason it’s difficult to get specific allegations of nonquantitative treatment
limitations (NQTL) violations is the lack of understanding on the part of providers about how to make these complaints. Covall maintains that providers are very good at appealing medical necessity determinations, because they’ve been doing it for a long time,but challenging insurance companies over NQTLs is not cut and dried. “You make these appeals to the insurance company, and they give you 18 different pieces about why they are in compliance.” It’s very complex, he said.
The difficulty is tied to the complexity and Covall is aware of the need to provide assistance to enable organizations to put forward the most targeted and relevant appeals and complaints. To that end, NAPHS and the Parity Implementation Coalition are working together to support such an effort.
Read part 1, Young battle managed care barriers