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By Phyllis Hanlon
When it comes to dealing with insurance carriers, most New England
psychologists agree that managed care desperately needs reform,
particularly in the areas of reimbursement and standardization of
forms. In some cases, steps are being taken to restructure the system
and close the communication gap between clinicians and insurance
carriers.
Dan Abrahamson, Ph.D., director of professional affairs for the
Connecticut Psychological Association, notes that some, but not
all, of the barriers to access and reimbursement for mental health
services in his state have crumbled. "Many of the laws in Connecticut
have addressed such things as the lack of mental health parity,
confidentiality, late payments, excessive waits for payment for
services," he says. "One of the things that none of the laws to
regulate managed care has been able to do is uncover the insidious,
hidden obstacles to access that managed care companies have constructed
over time."
"Phantom networks," are one obstacle. Abrahamson notes, "People
go to their directory of practitioners that is provided by the MCO
or the HMO, but then have to repeatedly call numerous people on
the list and find that nobody has an opening or availability or
they've dropped out of that plan and no longer participate."
Abrahamson points out that clinicians also face mounds of paperwork
to determine patient eligibility for services. A merry-go-round
of phone calls could lead to verification, with one caveat. "Insurance
companies put a warning on their recording saying the information
you receive is no guarantee that your claim is actually going to
be paid," he says. So the state's psychologists are mired in a Catch-22
situation. They want to provide services for clients, but face the
unpleasant prospect of claim denial once services have been rendered.
In a recent survey by the Maine Psychological Association, psychologists
unanimously proclaimed managed care reform, reimbursement and claims
issues to be top priorities. Confusion exists among the state's
five major carriers regarding co-pay amounts, payment at the correct
benefit level and timely reimbursement. Sheila Comerford, executive
director of the Maine Psychological Association, says that Anthem,
the state's largest insurer, has expressed willingness to discuss
the issues. "They're interested in helping resolve some of these
problems, so that is encouraging," she says.
Legislation requiring insurance companies to pay interest on payment
balances later than 30 days has improved the situation. Additionally,
an advocacy group, Reimbursement Oversight Committee (ROC), comprised
of psychologists, is spending significant time identifying problems
and working to find solutions. "ROC will develop some legislation
from the recommendations of the committee," Comerford says.
Vermont's licensed psychologists deal with similar reimbursement
issues. "An equally larger problem is the cumbersome, redundant
paperwork," says Jan Trepanier, executive director of the Vermont
Psychological Association. Numerous credentialing and outpatient
treatment report forms that vary from one carrier to another consume
valuable time that could, and should, be spent with clients, Trepanier
believes.
According to Trepanier, the dissemination of health care dollars
is also of great concern. "Vermont recently passed Act 129, whereby
the insurance companies must report where the money is going," she
says. "How much is utilized for administration and how much is utilized
for direct health care?"
Smallest of the New England states, Rhode Island faces monumental
challenges with insurance carriers. Peter Oppenheimer, Ph.D., Rhode
Island Psychological Association board member, says, "There is a
fundamental flaw in how the whole system is organized. There are
too many self-serving interests in having private health insurance."
He notes that carriers create a double standard that prevents psychologists
from abiding by professional ethics and providing necessary services.
"If you had a company that defaulted on you and six months later
when they still hadn't paid everything off, they handed you another
contract asking for the same terms, would you sign on? That's exactly
what Harvard Pilgrim did when they got Value Options. It was the
same clauses about not being able to go from unpaid money and charge
patients. So if anybody has a business and they short you, they're
done. But we can't cut off an insurance company that's doing that
even if they default. We are obligated to continue to see people,"
Oppenheimer says.
The fact that two insurance carriers dominate the health care industry
in the state complicates the picture. According to Oppenheimer,
the monopolies these companies have created are forcing some psychologists
to withdraw entirely from participating in the managed care system.
Psychologists are partially or entirely quitting insurance companies
because it is not economically feasible. "Blue Cross and Green Springs
were not part of Magellan yet, but made a deal where they were really
going to try to really clamp down on mental health costs. They came
up with this plan that would have put increasing burdens on us and
they wanted to cut fees significantly," Oppenheimer explains.
Rhode Island's size, however, has benefits as well. "Amongst the
health care professionals, there is a sense of 'We're in this together,'
so we really for the most part do work well with the doctors, social
workers and other groups," says Oppenheimer. Seven mental health
professions have united to form the Coalition of Mental Health Professionals
of Rhode Island and the Health Care Organizing Project, as well
as other advocacy groups.
Unique among its sister states, New Hampshire's psychologists are
enjoying a relatively positive relationship with carriers. "I have
to say from the way things were, it has calmed down with managed
care problems," says Kirsten Singleton, executive director of the
New Hampshire Psychological Association. "We have a strong mental
health coalition that works hard to hold the [carriers'] feet to
the fire. It could be that they've listened and changed their tactics."
Singleton says that there is general acceptance on the part of
clinicians regarding exactly what they'll receive from the insurance
companies. She admits that some of the state's psychologists are
opting to operate managed care free practices.
One ray of hope may come from the implementation of HIPAA regulations
in April 2003. "I'm hopeful, but cautiously optimistic, that HIPAA
will move us in the right direction of creating some administrative
simplification and efficiency that the insurance companies have
not been able to do on their own," says Connecticut's Abrahamson.
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