The United Healthcare Ruling and the Implications in the Addiction Community

On Tuesday March 5th, 2019 a federal judge ruled that United Behavioral Health, a division of United Healthcare, discriminated against patients seeking mental health and substance abuse treatment.

US Chief Magistrate Joseph Spero found that the insurer did not use ASAM (Addiction Society of Addiction Medicine) criteria appropriately to authorize care for patients and that the insurer put ‘bottom line’ over patients’ health.

ASAM criteria is a collaboration of the most widely used set of guidelines to assess addiction patient needs in an outcome-oriented approach. (An overview of the actual ASAM criteria can be found here.)

Denial of Coverage Trends for Mental Health Services

There is an alarming trend around coverage denials the country in treatment for behavioral health patients and providers.

A 2015 survey conducted by NAMI found that people seeking coverage for mental health services were denied at double the rate of those wanting medical services.

Another 2015 report from the Connecticut Insurance Department found that insurance plans were denied utilization review requests at a rate of one-third higher than they denied requests for other types of medical care.

A 2017 report by an actuarial firm detailed far lower reimbursement rates for mental health/substance abuse providers than other medical providers relative to Medicare.

Last year in California, AETNA Medical Director Jay Ken Linuma claimed, per protocol, that he did not even personally review patients’ medical records when deciding to approve or deny claims.

The issue is not necessarily just the insurers themselves. In many cases insurers don’t agree with providers regardless of whether ASAM is used. Medical necessity must be determined to authorize care, and is based on ‘prudent clinical judgement’, which will vary from provider to provider.

The real issue is that there is no fair 3rd party appeals process for the patients or providers.

A study from KFF found that among 42 million general healthcare claim denials, less than 0.5% of denied claims are even requested to be appealed.

The Kennedy Forum details a 2015 Consumers Union study that two-thirds of privately insured patients are uncertain about which state entity is responsible for resolving issues with health insurance billing, 87% do not know that state agency that handles complaints, and 72% are unsure if they even have the right to appeal.  There needs to be effective checks and balances system for claim denials.

Seeking legal remedy is a long process rarely patients can afford, and this is after significant damage has been done their health and finances. This can’t be the way patients have to get healthcare. 

The appeal process is detailed by the Kennedy Forum, calling it “complex” and “confusing”. This complex and confusing list of steps to file an appeal can be found here. Not only is the appeal process important for access to care, but for reconciling balance bills. A denied claim that had services rendered, passes all of the cost of the procedures from the insurer down to the patient.

Where do we go from here?

A consequence of denied claims is the effect on treatment outcomes. The drug rehab industry has been widely criticized for its low success rates. If providers are also blocked by insurers to treat individuals based on an outcomes-oriented treatment criteria (ASAM), how can we measure the success or failure of treatment providers correctly?

The real-life impact of these treatment decisions is scary.

How many United Healthcare patients were stepped down to a lower level of care when they weren’t appropriate for it?
A patient not ready for a lower level of care results in relapses or incidents far worse. This would be like rushing someone out of the hospital ICU and back into their home to deal with their issue on their own.

The decision of insurers to stray from ASAM criteria is confusing since it is an outcomes-oriented approach. Better outcomes mean healthier patients, healthier patients mean less utilization of services in the long run, and less utilization of services is a win for everyone. It would seem in everyone’s best interest to use ASAM criteria. Unless United Healthcare did not believe in ASAM criteria as having better outcomes. 

An outcome from this United Healthcare decision may be an adjustment to other insurance companies following ASAM criteria more closely. However, coverage for more behavioral health services may result in the insurer lowering reimbursement to providers to make up for the increase in volume. 

Without an effective appeals process, I guess we won’t know until the next 50,000 patients are forced to band together and file a class action.