I am insured by Harvard Pilgrim Health Care which sub-contracts to United Behavioral Health (UBH) the management of the mental health component of this health insurance. My policy allows for "unlimited medically necessary visits" and my diagnosis is included among the nine categories stipulated in the Mental Health Parity Law and my policy is not exempt from Parity.
My complaint is first, that UBH has informed my provider that it is unlikely that future care will be authorized and second has required the provider to undergo extensive and excessive reviews which involve requests for increasingly detailed information about me, purportedly to evaluate the medical necessity of the care provided. Third, the standards by which continued care, or Level of Care, are assessed are not transparent or even readily available to the provider or to the patient. As a provider, I have access to the UBH website where the LOC guidelines can be located after significant searching.
It seems that the reviewer has objected to the providers' reluctance to provide information that reveals specific details about current and past events in my life, at my request. I contacted the UBH phone number on my insurance card and reached the claims office, I asked if the person answering this call had authority to review and make decisions about claims or claim reviews. She indicated she did have this authority. After outlining this matter with Lorery, for twenty minutes, she contacted a reviewer to "see if they will talk to you" because she could not address reviews. I then waited quite a while and spoke to Lorery, who also did not have the authority to review the situation and who could not describe the level of care guidelines. She put me on hold and referred me the reviewer, Cheryl Lynn (my apologies if these are not spelled correctly). Cheryl Lynn refused to answer my question regarding the criteria for LOC assessment. This reviewer said that claims had not been denied and that the reviewer may decide that additional visits are medically necessary when the next review takes place. I pointed out my concerns about this which are: 1. That the reviewer had advised the provider to share with me that future services are unlikely to be authorized. The reviewer (Cheryl Lynn) reported there is no mention of this in her record 2. The provider is required to engage in lengthy and detailed review of care that is technically covered by mental health parity and has not received clear rationale for this level of oversight for the provision of once-weekly psychotherapy services. 3. Related to 2. The reason that the reviewer expressed skepticism about future authorizations is not that s/he does not view the care as medically necessary, but that the phrasing of treatment goals needs to be more "specific". My provider responded to this concern by indicating that the goals are stated in measurable terms at the same time they are stated in such as way as to avoid disclosing excessive detail about specific treatment issues in order to protect my confidentiality. When I shard this with the claims review department I was told I could not know "clinical information" because it is confidential – which reflects a misunderstanding of this point. The fact that this confidential information is also my information about my progress and well-being is ironic, but not part of this complaint. What is the focus of this complaint is that I was not seeking information about my case in particular, but rather the policy in general for how decisions about level of care are made, particularly when mental health parity is also in effect and what particular information in regards to goal setting is expected.
To my surprise, the person, Cherylynn, refused to answer and referred me back to the provider for discussion of this. I indicated that the provider and I have spoken and the reviewer indicated to the provider that future care would most likely be denied and that I was asking her what UBH's policy or review process involves when a patient qualifies under Mental Health Parity and is expected to meet Level of Care. Cheryl Lynn then hung up on me. I called back (routed once again through the claims department and then on to the review department; which by this point totaled nearly two hours of my time). Cherylynn did not take my call. Another reviewer did and explained that the provider was being asked for peer reviews because level of care guidelines were not met and so continued treatment could not be authorized unless the peer review found it medically necessary. Medical necessity includes the articulation of specific and measurable treatment goals.
The vagueness of this criterion, the lack of transparency for provider and policy-holder alike, as well as the excessive amount of information expected in order to authorize care that I am legally entitled to receive is the core of my complaint. The question of how an insurance policy that is legally mandated to cover medically necessary care can also create a series of processes that are time-consuming, obstructionist and lack clarity or accessibility by the client.
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