What struck me most about the new National Alliance on Mental Illness (NAMI) report on parity released this week is the observation that 29 percent of the 2,700 consumers surveyed said coverage for their mental healthcare had been denied by an insurer based on lack of medical necessity. Another 18 percent said the same of coverage for substance use treatment.
It makes me wonder exactly what data is fed into the decision-making engine that is used to approve or deny coverage. There’s nothing transparent about the process, and there’s no uniform criteria, according to NAMI. Some plans deny that which others approve, so clearly, insurers don’t agree on what is medically necessary in behavioral health.
In the black box
One source of input comes from state mandates. Each state regulates health insurance practice and can require coverage of certain benefits, such as autism therapy for children, for example. At least that’s one identifiable guideline we know for sure is included the black box of insurance approvals.
In Pennsylvania, Act 106 of 1989 quantifies minimum addiction treatment benefits for insurers in the state, such as seven days of detox per year or 30 sessions of outpatient per year. Advocates in New Jersey are attempting to pass a similar law with no qualifiers other than to say treatment must be approved for coverage by insurers simply because a prescriber said so.
In many behavioral health cases, prior authorization for services is not handled through an algorithm that’s programmed into a plan’s IT system, but rather, it’s handled by a human medical reviewer. The reviewer would rely in part on his or her professional medical opinion, which can be a nebulous thing to identify within the rationale for approvals and denials. You can see why several insurers in the same state might come to different conclusions on an identical case—it’s the human factor.
From the patient’s perspective, the denials (especially after the services have been delivered and the claim goes unpaid) appear to be based on cost alone. They often see more costly heart surgery and knee replacement services covered with reasonable out-of-pocket expenses for people they know, and they don’t believe their disorders are any less worthy of care and coverage.
For the insurer, what’s most often missing in the equation is the solid evidence that a certain treatment for a certain duration works for a certain type of patient. Why approve 90 days of residential treatment when outpatient treatment costs less and seems to deliver the same results based on what little data is available?
To draw an analogy, insurers are okay with everyone having shoes on their feet, but not everyone needs LeBron James basketball shoes at $160 a pair. So they opt to approve something more in the canvas sneaker range because that seems like a fit for most anyone and costs a fraction of the superstar basketball shoes.