Pre-authorization for mental health policy only lasted 5 days
January 6, 2011 8:51 AM   Subscribe

If you are a BCBS IL PPO large group policy holder with mental health benefits, you probably received a letter stating you were required to obtain pre-authorization for your visits. By doing so this could subject you to a change in care, a denial of care, and/or limits in visits. But if you follow mental health laws, Federal law states that limits/pre-authorization should not apply if your core medical coverage does not require such hoops. Well that fight was won after 6 days. The preauthorization has been lifted.
posted by stormpooper (14 comments total)
So happy about this. When I called the reps at IL one said that if you see multiple providers, the 10 "throw you a bone" visits were total for the year. Meaning if you saw someone for meds and someone for talk therapy you have to split it (5 and 5). Then preauthorize. If either of them gives conflicting diagnosis then you are denied. The other rept said it was 10 per provider (so a limit of 20).

All I can say is "ha!" Tired of games being played for mental health coverage.
posted by stormpooper at 8:53 AM on January 6, 2011

See, I knew this was blatantly illegal under federal law, and I'm a 22 year old software engineer. If I knew, BCBS obviously knew, yet they forged ahead anyway in the name of saving money. Want to bet that any potential fines won't come close to the amount they saved by setting up barriers to mental health care?
posted by zachlipton at 9:27 AM on January 6, 2011 [2 favorites]

So, a couple of years ago I'm stuck in ER, being the unlucky soul that ended up with it being "my turn" to wait with a family member who had once again overdone it on alcohol. The physician and I were talking about what needed to be done, and then we headed off to separate areas. The doc turned around, pulled me aside, and said, "You know, all of this would be much easier if this country and the insurance companies took mental health care and coverage seriously. You'd be amazed at how many of the people I see here are here because of addictions and mental illnesses. Just had to rant a bit there."

That stuck with me. Still, here we are, with mental health care being shoved to the back of the line.
posted by azpenguin at 9:38 AM on January 6, 2011 [2 favorites]

I didn't really understand what was being won here, but the last article made it a little more clear. The nut of the federal law is that mental health benefits can't be treated differently than 'regular' benefits. That is, if you don't need pre-authorization to see a doctor about an earache, you can't be required to get it for mental health stuff.

I still don't understand what this has to do with the 'throw you a bone' visits. Can you elaborate, stormpooper?
posted by JohnFredra at 9:38 AM on January 6, 2011

I asked why was this happened and they said that Magellin was no longer managing the contract, that BCBS IL was and didn't know if this was a long term necessity or a temp during transition.'ve been around a really long time as an insurace carrier yet you need to preauthorize to control costs because you can't figure shit out?

Nothing like stressing out those who are seeking help for being stressed out. So f'in stupid.

My and my DH (as well as our provider) didn't like the fact that this pre-authorization opened up to more scrutiny of diagnosis, care, and sharing of that knowledge. And the people who share that knowledge are life insurers and on a remote chance say a divorce. If you get a diagnosis of depression or post partum depression it can affect your policy or your custody.

Always request a carefree, lacksadaisy diagnosis. Huge difference in impression between dysthimia or generalized anxiety vs major depressive episode/PTSD/Postpartum Anxiety.

Screw that noise.
posted by stormpooper at 9:40 AM on January 6, 2011

@John. The "throw you a bone" vists were 10 visits (per provider? per member? They couldn't agree) a year where you don't have to per-authorize. So if your treatment, say meds, was only 10 visits for the entire year, you didn't need to get a special authorization to give to the provider and be subject under these rules and risks of denial and limitation of care.

But if say you were under med and talk therapy treatment you could go through those 10 non-authorized visits pretty quickly. The risk was if they couldn't agree on a diagnosis (for example my med doc already screwed up my ICD codes and my other doc uses CPT codes) then all care would be denied under this new rule.

I chose PPO because the core principle of PPO coverage was no pre-authorizations for any medical treatment (minus in-patient hospital stays). I can see any doctor, as many doctors as I like--general to speciality--without any of them pre-authorizing each other. If I wanted to jump through hoops to save costs, I would have selected HMO.

This mental health preauthorization jazz was making me pay premium PPO care, work like an HMO, and risked my medical care because I needed to see not only med treatment but talk therapy treatment. No other care that I have ever gone through has asked for this. Even my infertility treatments only required 1 year of trying. I didn't need my OB/GYN to tell the RE that hey thinks aren't working so let's limit her care to only Clomid.
posted by stormpooper at 9:44 AM on January 6, 2011

The mental health act also allowed for unlimited visits. In the past, people who were abused or have substance abuse should have "gotten over it and suck it up", in the insurers eyes with their 30 visits a year. The Fed law made huge leaps and bounds so people can get the care they need for as long as they need it. Some things take a lifetime to get over or manage. I've been dealing with depression since grammar school and only since my 20s have I sought to manage it (on and off). All I know is I'm proactively seeking help like healthcare wants yet pre-authorization was all about 'now wait a minute...we'll see if you REALLY need this care." So stupid.
posted by stormpooper at 9:49 AM on January 6, 2011

So stupid.

It is. Until you remember that for insurers like BCBS, their bottom line is profit, not your health. Their most important clients are their shareholders, not you.
posted by rtha at 10:03 AM on January 6, 2011 [1 favorite]

Actually, though this was certainly a clusterfuck, BCBS Illinois is non-investor owned.

There are no shareholders to make happy - only corporate customers to keep happy by keeping costs down.
posted by MCMikeNamara at 11:13 AM on January 6, 2011

Can someone explain what this means in English, for those of us who live in a country with free healthcare[*] provided by the government?

[*] At the point of delivery, obviously.
posted by cstross at 11:17 AM on January 6, 2011

@cstross. In theory, it meant you had to go to the insurance company and the provider to ask for permission to have the provider continue your care based on a diagnosis. If the insurance company felt that say a diagnosis of depression should have been resolved in 15 sessions, then that's it. You don't get any more sessions covered by the insurance company. You pay out of pocket.

Our Federal mental health parity act said that if your core medical insurance coverage (diabetes, cardiac, routine physicals) does not require such "permission" and limitations by the insurance company, then your mental health coverage should be treated the same way. And the mental parity act stated that mental health visits should not be limited (they used to be limited to 30 sessions a year).

Mental health professionals pointed out to the insurance commission this new permission system went against Federal law so they clamped down on the insurance company. Thus the insurance company said "my bad" and canceled the "get permission first" clause.

We're back to unlimited visits and go to whomever we want as many times as we want.

Does that help?

The insurance company said the reason why they did it was to contain costs. If mental help professionals saw everyone at will for however long they want, the costs rise because providers get a reimbursement rate below what their standard charges are.

Yes. It's complicated.
posted by stormpooper at 1:27 PM on January 6, 2011

Well, there is the issue of parity. Insurers could save a LOT of money by requiring preauthorization for any and all visits, both conventional medical and mental health. You know that this is coming up in management meetings, the only thing stopping them is the question " Can we get away with it?"

American health care /nelsonlaugh
posted by Xoebe at 1:36 PM on January 6, 2011 [1 favorite]

@xoebe, then wouldn't you also think they would have to get rid of a PPO option across the board, which doesn't require preauthorization? HMO was tooted "Save money" and that fell like a ton of bricks because of the whole preauthorization b.s.
posted by stormpooper at 1:39 PM on January 6, 2011

Thank you for this post. I had no idea about the Mental Health Parity Act.

That certainly explains why I was charged $10 more than my copay for a psych visit (meds) because I had a non-parity diagnosis (ADHD) in October 2009 and then have never been charged more than my copay since then.

And extra good news about no more visit limits. I'll stop rationing my therapy sessions to make sure I have enough at the end of the year when SAD comes calling.
posted by elsietheeel at 2:31 PM on January 6, 2011 [1 favorite]

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