Physicians are taking on the issue of mental health parity in a case against UnitedHealthcare, claiming the payer has “systematically implemented unlawful and deceptive practices.”

The New York State Psychiatric Association (NYSPA) in March 2013 brought a class action lawsuit, representing its members, alleging violation of various state and federal laws, including the Mental Health Parity and Addiction Equity Act, the New York Parity Act and the New York Prompt Pay Statute.

The lawsuit claims that United’s practices were “designed to create the illusion of impartiality, fairness and due process while simultaneously undermining access to treatment for the most vulnerable segment of our society.” Among the complaints:

  • The payer has used internally developed, unjustifiably restrictive guidelines to determine the medical necessity of behavioral health and substance abuse services—guidelines that are inconsistent with standards generally accepted in the mental health community.
  • The payer has required “clear and compelling” evidence that psychotherapy services at proposed frequencies are medically necessary, while medical services not involving mental health treatment are only required to demonstrate that there is reasonable probability a patient may require treatment.
  • The payer has delayed treatment preauthorizations even when treatment requires continued approvals. United also uses review practices for outpatient mental health services that aren’t comparable to—and are more stringent than—review practices applied to medical procedures that don’t involve mental health treatment.

In respect to the lawsuit, United has challenged NYSPA’s legal standing to represent the interests of its members and its members’ patients. A trial court dismissed the suit in October, partly on the grounds that NYSPA lacked this standing.

Last month, NYSPA filed an appeal in the 2nd U. S. Circuit Court of Appeals. The Litigation Center of the AMA and State Medical Societies and the Medical Society of the State of New York filed an amicus brief to support NYSPA, calling out the AMA Code of Medical Ethics as the basis for why NYSPA does have legal standing to advocate for its members and its members’ patients.

“Chief among the precepts which guide medical ethics is the concept that a physician acts in a fiduciary capacity to his [or] her patients, and that a physician is ethically bound to place the interests of patients ahead of the physician’s own interests, including the physician’s own pecuniary interests,” the brief states. “Physicians are in a unique position to advocate for their patients’ interests …. [NYSPA] is standing in the shoes of its members in so advocating for their patients.”

The brief also touches on the social stigmas mental health patients face, and the difficulty these patients may have in bringing litigation because of public exposure and the possibility of having to involve their employers.

“The patients suffer social stigmas and other obstacles preventing their remedying these violations except through the aid of their psychiatrists,” the brief states. “Due to the pervasive nature of the violations, an association of psychiatrists can and should lead the legal effort to right those wrongs.”

While 18-25 percent of U.S. adults experience a mental illness each year, only about 39 percent of these individuals receive appropriate treatment, according to data from the U.S. Department of Health and Human Services. 

“Financial barriers to mental health treatment must be eliminated as the inability to afford mental health care is reportedly the main reason individuals do not seek care,” recent AMA report states. 

Mental health and substance use disorder services are considered an essential health benefit under the Affordable Care Act, and the Mental Health Parity and Addiction Equity Act requires group health plans and health insurers that provide mental health and substance use disorder benefits to provide the same level of benefits as they do for medical and surgical treatments.

 

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