Mental Health Care Denials Received Most Consumer Complaints During First Year of Massachusetts Patients’ Rights Law

Patients seeking state reviews of health plan decisions under Massachusetts' one-year-old patients' bill of rights most often ask the state to reverse denials of care related to mental health treatment, the Boston Globe reports. Under the state's law, patients are first required to exhaust an internal review process with their insurers before appealing denials of care to the state. In a review of patient appeals to the state, the Globe found that of the 137 appeals filed by patients last year, the "largest category" -- 35 -- concerned mental health care treatment decisions. Most of the appeals concerned patients seeking mental health treatment from out-of-network therapists or drug abuse and depression treatment from a hospital on an inpatient basis. Health plans typically denied out-of-network coverage for "cost and quality reasons" and hospital stays because they were "not medically necessary," the Globe reports. Patients in Tufts Health Plan filed the most mental health appeals -- 16 -- with the state. Five mental health reviews were sought by Harvard Pilgrim beneficiaries, and seven mental health appeals were filed by beneficiaries of Blue Cross & Blue Shield of Massachusetts. In 45% of the mental health appeals, the health plan's decision was upheld by the three private companies with which the state contracts to handle the reviews. In the other cases, the appeals usually were resolved before the reviewers made a decision.

State Plans Review of Health Plans
State officials said that even though the appeals process typically upheld health plan decisions, the fact that patients are filing complaints may "indicate broader problems." Nancy Ridley, assistant commissioner of public health, and Marylou Sudders, the state's mental health commissioner, said they plan to conduct a review of health plans' internal mental health appeals to obtain more information. In addition, the state Division of Insurance plans to investigate whether health plans have a sufficient number of therapists in their networks, a requirement of the patients' rights law. In the meantime, state officials said they plan to send a letter to insurers in the next few days to "outline the requirements" for health plans' mental health networks, such as therapists who can treat all age groups and types of illnesses. Ridley said, "We really want to get the message across that we see challenges [health plans] need to open their eyes to. It's a wake-up call to managed care organizations about the problems we're seeing." Sudders added that the state has enough "snippets" of information to make officials concerned, but not enough to determine whether health plans are violating any laws. "In my heart of hearts I think there's an access issue, but we need more information," she said (Kowalczyk, Boston Globe, 2/14).