ObamaCare to fix holes in mental health benefits: a case study

Friday, January 25, 2013

By Michael Grodsky, founder, HealthInsuranceForArtists.com

In January 2014 the Affordable Care Act will require insurers to cover more mental health services in all health plans, benefits that are currently mandated only in health plans offered by large employers. LA Times reporter Noam Levy writes ”that among the biggest barriers to treatment have been cost and limits placed on care by insurance companies.” (Noam Levy, 1/19/2013, Obama intends to fix holes in mental health coverage; www.latimes.com)

Acronym & Vocabulary Lesson!
• CPT code = Current Procedural Terminology Code (also known as a billing code).
• UCR rate = usual, reasonable, customary rate for a treatment in a given geographic area.
• EOB = Explanation of Benefits (sent by insurance company to show who paid what).
• Grievance form. Grievances include both complaints and appeals. Complaints can include concerns about people, quality of service, quality of care, benefit exclusions or eligibility. Appeals are requests to reverse a prior denial or modified decision about your care.

Client Case Study
Josh’s teenage son Oliver (not their real names) was diagnosed with OCD (obsessive-compulsive disorder), and Josh found a highly regarded outpatient facility that featured a month-long intensive treatment program. It cost $24,000, a big chunk for anyone, but Josh was determined to help his son get well, whether that meant using retirement savings or trading in their home's value.

The treatment facility and doctor were not in-network with any insurance plan, but the family’s PPO policy covered 50% of the UCR cost up to 20 days per year. From a conversation with the insurer’s representative we learned the UCR rate for CPT code 90808* (not a zip code!) was $375, meaning the insurance company’s 50% share would be about $187 per day after Oliver’s $2,000 non-network deductible was met.  *CPT code 90808 = Outpatient Individual medical psychotherapy, 75 – 80 minutes

Yet when the EOB was mailed to Josh, he discovered the insurer’s covered amount per treatment was $137, not $375, of which the insurer paid only half ($69 per day). Did the medical provider incorrectly label the billing code as an office visit instead of “individual medical psychotherapy?” 

It turned out the correct code was applied, and there were four treatments each day, instead of the one treatment per day listed on the EOB. This was likely an oversight of a busy medical billing department, but thankfully the doctor provided Josh with a "To Whom It May Concern" letter that asks the insurer to give credit for four treatments per day. Josh attached this letter to a Grievance form downloaded from the insurer's website, and faxed everything to the number on the form.

As of this writing, the insurer has paid only $788 of the $24,173 bill. The issue of what is the correct reimbursement amount ($375 or $137) has not been resolved. It remains to be seen if credit for four treatments per day will be allowed. To be fair, the insurer was not initially provided with the correct number of treatments. And the underlying problem, how to effectively access mental health benefits, is not something you can blame the insurer for because is competing in the individual and family marketplace with all other insurers. 

Instead, this is a public policy matter, and fortunately people with mental illnesses will significantly benefit from health insurance reform with the changes coming January 2014. The details are still being worked out, but know, for example, that autism and acupuncture benefits are provided in what is called Essential Health Benefits.

This struggle for mental health benefits is one hole that cannot be fixed soon enough!

Author Bio
Michael Grodsky, AIF, is founder of Aquarius Financial & Insurance Services, providing unbiased education and access to health insurance for Californians. He is a board member of Side Street Projects, a non-profit artist-run organization, and is an insurance and financial planning specialist for GYST, an artist-run company providing information and technology solutions for artists. Michael’s Health Insurance 101 workshops have been hosted by non-profit organizations throughout Los Angeles County.  He leads the ‘Health Insurance 101’ monthly informational workshop at the Cancer Support Community-Benjamin Center.

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