Under a series of federal laws, medical insurers must provide equal insurance coverage for behavioral health treatment and for medical and surgical care. Otherwise, payers and insurance policies tend to cover mental health treatment at lower levels than physical illness.
Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008, requiring equal coverage of treatment for mental illness and addiction, known as mental health parity. In November 2013, the federal government released rules for implementing the law.
However, not all insurers have followed this rule for equal coverage. America’s Mental Health 2018, a study of access to mental health care in the United States, found that 42 percent of Americans considered “cost and poor insurance coverage” to be some of the largest hurdles to mental healthcare access.
Lack of insurance coverage for mental health treatment can be devastating for patients with substance misuse and serious mental health disorders. It can also create problems for behavioral health providers when payers deny prior authorization or insurance claims.
Mental Health Parity and the Wit Case
If payers have restrictive guidelines for care, even providers that follow generally accepted standards may have to justify their treatment decisions. This issue came to a head in Wit v. United Behavioral Health, also known as the Wit case.
In March 2019, the U.S. District Court for the Northern District of California found that United Behavioral Health (UBH) wrongfully denied plaintiffs coverage for mental health and substance use services. UBH’s Level of Care Guidelines and Coverage Determination Guidelines were more restrictive than general standards of care.
In its ruling, the court listed eight principles of accepted standards of care. Both patients and providers can refer to these principles when seeking or providing appropriate behavioral healthcare:
Treating the underlying condition, not just current symptoms
Coordinated treatment of co-occurring behavioral and physical health conditions
Treatment should be the least intensive and restrictive while also safe and effective
When uncertain, err on the side of caution and place a patient in a higher level of care
Behavioral health treatment should maintain functioning or prevent deterioration
Duration of treatment has no specific limit
Account for the unique needs of children and adolescents
Appropriate level of care should use a multidimensional assessment
How to Advocate for Behavioral Health Clients and Practices
Drawing from the Wit case, National Council for Mental Wellbeing has developed a toolkit, “A Compelling Argument For Facilitating the Equitable Use of Generally Accepted Standards of Care,” available as a PDF download.
The toolkit aims to help behavioral health clinicians and organizations claim their roles as expert authorities and ensure that clients receive appropriate, medically necessary care. It is meant for providers whose claims have been denied due to misaligned standards of care.
The toolkit includes:
Appropriate steps to take when faced with excessively restrictive claims denials
An infographic highlighting the Wit case
Appeal letter templates for both providers and clients
Talking points to use in phone conversations with reviewers
These resources can help your behavioral health organization better advocate for your clinicians and your clients while demonstrating your expertise and conviction.
Behavioral health billing and reimbursement shouldn’t be complicated. BestNotes EHR solutions were developed specifically for behavioral health and substance use disorder treatment providers to help you operate with less stress and frustration, helping you stay compliant and get reimbursed faster. Contact BestNotes today to learn more.
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