AMA Wit v. UBH Brief Says Guidelines May Be “True Star”
The American Medical Association (“AMA”) has issued a brief on the Wit v. United Behavioral Health (“Wit v. UBH”) court ruling, saying that it “highlights pervasive violations denying patients adequate care for mental illness and substance use disorder.”
The document reviews key aspects of Judge Joseph Spero’s decision, such as the court finding that guidelines developed by medical societies were authoritative sources. “Guidelines developed by the nation’s medical societies may be the true star of the ruling,” states the brief, citing a list that includes ASAM criteria, the AACP Level of Care Utilization System, CALOCUS, CASII and the CMS Manual.
The document also explains why policymakers should pay attention to this decision and how this ruling can help guide further medical society advocacy. The AMA notes several court findings that it says could help state regulators determine whether the policies of other payers and behavioral health companies are following generally accepted standards of care.
The cited findings include that:
• Effective treatment address chronic, underlying conditions.
• Placement in a less restrictive environment is appropriate only when it is deemed likely to be safe and as effective as a higher level of care.
• Threshold requirements for admission and continued service be relaxed when making treatment decisions focused on children and teenagers.
The brief also says that by using a benchmark of “acute” symptoms, UBH consistently denied coverage for higher levels of care—and could also deny approval of lower levels of care due to a lack of those symptoms.
“Therefore, if a payer or behavioral health management company is taking similar actions,” writes the AMA, “those decisions arguably are not only violating the medical standard of care, but like the patients who brought the action in Wit, patients in other states may currently be experiencing harm due to coverage denials based on the payer or behavioral health management company guideline that prefers financial interests over safe and effective patient care.”
The full document, ARC Issue Brief: Wit v. United Behavioral Health, can be found here.