Physician Patient

Up to their old games: Minnesota insurance companies are denying mental health claims

Up to their old games?
Undeniably, denying claims is the managed care business model. “Captain may I” managed care prior authorizations and claims denials are the dominant health care rationing strategies of Minnesota insurance companies and third party administrators (TPA) contracted by self-funded corporations.
United Healthcare (which originated in Minnesota) is the reigning champion of these practices.
Claims denying is used extensively for managing mental health claims. That’s why mental health advocates pushed for mental health parity laws. However, the deal-breaking caveat for implementing state and federal mental health parity laws to expand coverage is this: Medical necessity is determined (defined and decided) by the managed care company itself, not by the patient’s health care “provider” (physician, psychologist, social worker, etc.), or an independent arbitrator, or most importantly by the consumer (patient and family). And the denials can occur before, during, or after treatment is provided.
I left employment as a mental health medical director at a large Minnesota PPO years ago because I couldn’t work for an enterprise that advertised and competed with other managed care companies touting its effectiveness in denying patients’ mental health claims.
How best to fight third party mental health claims denials? Stop contracting with third parties. Most Minnesota physicians are now employees and their organizations do the dirty work. Independent doctors can be paid by their patients. And patients themselves can get payments from their insurance companies.
Complaints and public pressure require tireless and Sisyphean efforts on the part of both doctors and patients. The managed care stone always rolls back on one; its corporate economic power and mass exponentially growing. When patients have skin in the game they will complain. And patients’ complaints matter most when they are reinforced by other patients and community mental health advocacy organization such as NAMI-Minnesota. Or if the rolling stone is an asteroid law suit involving lots of public money and taxpayers. [See the Westin case and MN AG Mike Hatch’s suit against BCBSM in 2001 http://news.minnesota.publicradio.org/features/200106/19_stawickie_bluecross/]
Uncollected accounts receivable in a private practice? The bigger they become the more the doctor is pushed into giving up her independent practice. That’s part of the UHC playbook as well.

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