Blue Cross retreats on preapproval for therapy

By Bruce Japsen
Posted Jan. 5 at 1:09 p.m.

Blue Cross and Blue Shield of Illinois has dropped a plan to require health plan subscribers to get prior approval before getting access to a broad range of outpatient mental health services, amid intense criticism.

Blue Cross and Blue Shield of Illinois upset mental health providers and their patients throughout the state in recent weeks with a requirement that preferred provider organization, PPO, health plan subscribers first call the insurer to get prior approval before being able to get most outpatient mental health counseling, psychotherapy or other outpatient medical health services.

“This would have served as a subtle deterrent to getting care,” said Paul Pendler, a clinical psychologist in private practice in Chicago. “Anytime you put limits or a requirement to pre-certify for access to services brings a higher likelihood that people will say, ‘forget it’ and not get treatment.”

The move comes at a time health insurance companies are trying to wrest control of rising health care costs with their pool of insured customers dwindling amid high unemployment and more Americans dropping their medical care coverage. Meanwhile, the health care overhaul law that will bring subsidies for 30 million Americans to buy health benefits does not kick in for another three years.

Insurance companies say they generally institute pre-authorization so they can begin a process of managing a patient’s medical care.

In an internal Illinois Blue Cross memo obtained by the Tribune that was sent to mental health providers, the insurer said the intent of its preauthorization program was “to improve coordination of care between medical and behavioral health care providers.”

In addition, the preauthorization was designed to give health plan members “guidance regarding care options and available services based on their benefit plan” and to help “indentify co-existing medical and behavioral health conditions earlier.”

But mental health professionals say pre-authorization of mental health services violates federal law under the Mental Health Parity and Addiction Equality Act, which is designed to make mental health services no different than other medical services. Such coverage is not mandated but the law requires such benefits be equal if offered by an employer.

For example, a person in a preferred provider organization, or PPO, with a sore knee does not have to call his or her insurance company to get pre-authorization to see his or her primary care professional several times if the pain does not go away and a patient needs more counseling, a prescription or treatment.

Complaints drew interest from Illinois Insurance Director Michael McRaith, whose staff has been meeting with Illinois Blue Cross in recent weeks. Among those criticizing the health plan were hundreds of health professionals from the Illinois Psychiatric Society and the Illinois Psychological Association.

“The Department of Insurance is committed to the principle set forth in (the mental health parity law) that coverage for mental health or substance abuse use disorder benefits must be equivalent to coverage for other benefits,” McRaith said today. “In the event that ambiguity is argued to exist in the implementation (of the law) or its regulations, the department will resolve such ambiguity in favor of the patients and families for whom the law is meant to protect.”

Medical care providers say it makes little sense to curtail usage of outpatient mental health services that generally cost a health plan $100 to $150 a visit depending on the rate negotiated with the medical care provider. Depending on the patient’s health plan, the insurer would pay the bulk of the cost minus a co-payment or deductible for an outpatient service designed to keep a patient healthy and out of a more expensive hospital setting.

“Consumers pay $50 to $10 to nothing for visits that are about $100,” said Chicago clinical psychologist Pendler. “In today’s health care, there is no value in managing the least expensive service. It’s something that is costing $100 a pop, which is nickels in the bucket when you think of people getting well from such care and reducing the likelihood of all sorts of more expensive (care).”

Illinois Blue Cross would not disclose how many of its health plan members use outpatient behavioral health plan services but said the policy was limited to its PPO plans, which are the most popular choice sold by the company. Illinois Blue Cross has 6.7 million health plan members.

Illinois Blue Cross said there would still be pre-authorization for certain services such as “behavioral health partial hospitalization, intensive outpatient programs at facilities, all outpatient electroconvulsive therapy and psychological and neuropsychological testing,” said Dr. Scott Sarran, Illinois Blue Cross chief medical officer.

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  1. Kevin Jan. 5 at 9:58 a.m.

    Hey all you right-wing Republicans and Tea Partiers, after reading this article can you honestly tell me that health care reform was a bad thing?

    Any honest person can tell you the current system is a mess and needs to be reformed to better protect individuals, not for-profit companies.

    Republicans had control of the executive and legislative branch for 6 -8 years and did absolutely nothing to reform health care. All of sudden, when a Democratic president and congress manage to address the issues, Republicans are johnny-on-the-spot to repeal the law but haven’t offered any suggestions to replace it with something better.

    As Americans, we need to address our health care delivery system to cover everyone – like every other first world country. If people didn’t have to fear bankruptcy caused by medical bills, more people would start small businesses and a dignified retirement would not be an unattainable dream.

  2. Bob in Chicago Jan. 5 at 1:47 pm

    Oh Kevin….you couldn’t be more wrong …you liberal water carrier !!!

    Are you nuts?

  3. 007 Jan. 5 at 3:41 pm

    Kevin, we haven’t even SEEN what health care “reform” has brought.

    You may be disappointed when you find out it’ll be the government controlling your care, or lack thereof, instead of the nasty insurance company…..

  4. Jeremy Engdahl-Johnson Jan. 5 at 9:50 pm

    More on mental health parity: The safe harbor for outpatient benefits,