New Toolkit: A Path Forward for Appealing Denials of Coverage
Here’s a sobering truth: Sometimes insurers deny coverage of more intensive levels of care for reasons that are not consistent with the actual current community standards of care.
The guidelines followed by mental health and substance use service providers and insurers – known as “utilization management standards” or “medical necessity criteria” – don’t always match up, which can impact the degree and quality of care one receives. A landmark case last February emphasized as much.
On February 28, 2019, Judge Joseph Spero of the United States District Court for the Northern District of California issued the findings of fact and conclusions of law in Wit v. United Behavioral Health (Wit case), a class-action lawsuit brought against the country’s largest behavioral health insurer.
In deciding the case, the court enunciated eight general standards of care applicable to service intensity and patient placement selection for behavioral health care and applied them to the guidelines and practices of UBH operations. The groundbreaking result: A clear set of generally accepted standards of care that is consistent with widely accepted professional sources of standards.
In August, the National Council’s Medical Director Institute (MDI) discussed these standards and issued a statement of their position on the issue. MDI co-chair, Dr. Joe Parks, also co-authored an article about the Wit case. And just this month, the National Council introduced a new toolkit to empower behavioral health providers to claim their role as an authority on generally accepted standards of care.
Developed with input from various mental health and substance use disorder organizations, the toolkit is designed for providers who are appealing the denial of care and have questions about the best path forward. It provides a compelling argument for upholding generally accepted standards of care, as well as practical tools for implementing an effective appeal strategy. The toolkit’s recommended approach supplements general appeal guidance with important findings from the Wit case.
The National Council is committed to bridging the gap in how generally accepted standards of care are understood and applied by payers and providers. To learn more, contact Lindsi DeSorrento, Director of Healthcare Transformation at the National Council for Behavioral Health.