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Are Flawed Denial Guidelines Being Used for Your Behavioral Health Coverage?

A recent court ruling found that United Behavioral Health (UBH), a division of United Health Group, used overly strict criteria for denying care, potentially excluding significant number of members, including children and adolescents, from accessing behavioral health services. Specifically, the court ruled that UBH violated it's fiduciary responsibilities and also failed to recognize chronic and complex behavioral health conditions and needs.

Read the article  on the court's ruling from Health Payer Intelligence.

What can you do to better understand the denial guidelines, and other policies, used by your health plan or behavioral health manager? Here are some suggestions:

Re-evaluate the results of the National Alliance's mental health deep dive in light of this ruling. Pay special attention to the section on Accreditation and Parity (page 14) to better understand that parity also applies to non-quantitative treatment limitations. The call-out box specifically refers to medical management standards limiting or excluding benefits. Check with your legal counsel and advisors re: the implications of excess denials re: these parity requirements.

Check out proposed FAQ's from HHS, DOL, Treasury on parity and the 21st Century Cures Act. 

Use this form to collect data on your actual denial rates. Compare behavioral health to medical/surgical denial rates to get a clear picture of this issue for your organization.

Use this model language and consider seeking indemnification from your vendor for certain aspects of parity non-compliance. 

Contract with an objective third-party vendor to audit parity compliance. Memphis area results from the national employer survey on mental health indicate that few external audits are being conducted.

Posted by Cristie Travis at 3:22 PM

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