Psych-Appeal and Zuckerman Spaeder LLP have filed a class-action complaint alleging mental health parity law violations by United HealthCare Insurance Co. (“UHIC”) and United Behavioral Health (together “United”). The class action alleges that United imposed arbitrary reimbursement penalties on psychotherapy services provided by psychologists and master’s level counselors.

The dispute centers around the amount United would pay for the plaintiff’s covered treatment for her post-traumatic stress disorder, which included individual counseling from a Licensed Clinical Social Worker (“LCSW”) with post-graduate training. Since the provider was considered out-of-network, benefits were based on an “allowed amount,” which is the maximum amount eligible for reimbursement.

The plaintiff in this case alleges that United Healthcare Insurance Co. and United Behavioral Health have a policy that allegedly results in parity violations because it reduces the “allowed amount” of covered charges by 25 percent when provided by a psychologist and 35 percent when provided by a master’s level counselor (i.e., an LCSW). As a result, anyone receiving psychotherapy services from a psychologist or social worker is subject to reduced reimbursements. The plaintiff argues that these arbitrary reimbursement penalties violate the Federal Parity Act and the Affordable Care Act by discriminating against patients seeking behavioral health services from such providers.

“Outpatient psychotherapy plays a critical role in the recovery process for patients in need of ongoing mental health treatment,” said Meiram Bendat, co-counsel for the plaintiff and founder of Psych-Appeal. “United’s actions to artificially devalue the services of psychologists and social workers may boost revenues and shareholder profits, but it is a systemic denial of benefits to health plan participants and beneficiaries. Health insurance companies like United must be held accountable for flouting parity laws that were put in place to prevent such discriminatory practices.”

The complaint was filed in the U.S. District Court for the Northern District of California. Today’s filing follows a New York federal judge’s ruling in August regarding a similar complaint filed by Psych-Appeal and Zuckerman Spaeder against Oxford Health Insurance Inc., which is also owned by UnitedHealth Group.

Related coverage: United Healthcare Sued For ‘Arbitrary’ Therapy Payment Policy, Law360, October 17, 2018 (NOTE: This link is available to Law360 subscribers.)

A federal judge has ruled that a lawsuit alleging that Oxford Health Insurance (“Oxford”), owned by UnitedHealthcare Insurance Company and UnitedHealth Group, applies discriminatory reimbursement policies for psychotherapy rendered by psychologists and master’s level clinicians will proceed.

U.S. District Judge Ann M. Donnelly said Monday that the class-action complaint, filed by Psych-Appeal and Zuckerman Spaeder LLP, sufficiently alleged that Oxford imposed arbitrary reimbursement penalties on psychotherapy.

The plaintiffs allege that Oxford reimburses out-of-network psychotherapy provided by psychologists and master’s level clinicians at rates 25 percent to 35 percent less than it does for medical doctors, who may not even have specialized mental health training. The plaintiffs argue that Oxford’s reimbursement policy artificially devalues psychotherapy and restricts access to this essential health benefit, and that it violates the Federal Parity Act and the Affordable Care Act.

“There is no similar treatment restriction for medical/surgical healthcare benefits,” said Judge Donnelly in her order.

Doe v. UnitedHealth Group Inc. et al was filed in the U.S. District Court for the Eastern District of New York.

Previous news: UnitedHealth Group Complaint Filed Alleging Violation of Parity Laws for Psychotherapy Services

 

Related coverage: Oxford Can’t Duck Claims In Psychotherapy Benefits Suit, Law360, August 22, 2018 (NOTE: This link is available to Law360 subscribers.)

Though it’s often overlooked, an essential skill for in-network psychiatrists is learning how to negotiate a managed care contract. That’s because for many psychiatrists, it takes a claims denial before they set aside time to look into their rights—and realize they have very limited recourse.

If this describes you, don’t despair. In a guest column for the American Psychiatric Association’s Psychiatric News, Psych-Appeal’s Meiram Bendat says you’re not alone. The vast majority of providers pay little attention to the fine print when they sign a managed care contract and are unaware that these agreements tend to be highly restrictive, one-sided contracts that offer minimal protection to healthcare providers.

The consequences of entering into these lopsided agreements can be significant.

Fortunately, as Bendat writes, there is a solution. Since the law generally permits consenting parties to negotiate contract terms that do not violate public policy, providers can negotiate network agreements that:

• Reject arbitration clauses or class action waivers.
• Insist on sufficient time frames in which to file administrative appeals.
• Establish access rights (even electronically) to mental health parity analyses and utilization review data before filing appeals.
• Limit utilization reviews to specified frequencies, durations, and information.
• Require interest for untimely processed claims.
• Prohibit retrospective reviews of preauthorized claims.
• Prohibit recoupments of paid claims after a set period of time.
• Mandate automatic reversals of denied claims when managed care companies fail to respond to data inquiries and/or appeals within established time frames.

This isn’t to say that managed care companies will agree to the above terms in a contract or be willing to negotiate with psychiatrists. That’s why it behooves professional associations to support their members by advocating for uniform due process terms in managed care contracts. Uniformity of these terms would not only promote psychiatrists’ business interests, but also enhance their ability to most effectively care for patients.

As a law firm exclusively specializing in mental health insurance advocacy, Psych-Appeal has had a number of recent successes — and they’ve caught the attention of The National Law Journal.

Last week, a U.S. District Court judge granted class certification in a lawsuit against Blue Shield of California and Human Affairs International of California, Inc., a subsidiary of Magellan Health, Inc. That decision is the latest in a series of high-profile rulings for Psych-Appeal and Zuckerman Spaeder LLP.

In “Niche-Market Lawyers Battle Insurers’ Disparate Treatment of Mental Health Claims,” reporter Kristen Rasmussen looks at several cases filed by Psych-Appeal and Zuckerman Spaeder. These cases have taken on some of the giants in the health care industry, from Blue Shield of California and Aetna to Cigna and UnitedHealthcare. The commonality? All have been filed with the intention of holding health insurers accountable for improperly denying mental health and substance abuse treatment.

“Th[ese] cases have been successful because they speak to systematic abuses that are relatable, and the remedies we are seeking are just intrinsically fair. They’re requiring the insurers to essentially conform their practices to the proper standard of care,” said Meiram Bendat. Dr. Bendat is the founder and president of Psych-Appeal and was interviewed by the Journal about the law firm’s successes.

Dr. Bendat’s background in clinical psychology, marriage and family therapy, and psychoanalysis, has served the law firm well as it advocates for patients and providers to overcome insurer denials of mental health treatment claims. Partnering with Zuckerman Spaeder on numerous class actions, the two law firms have become a powerhouse in mental health parity litigation. Psych-Appeal is also working with the Parity Implementation Coalition, the Saks Institute for Mental Health Law, Policy, and Ethics, and The Kennedy Forum to break the stigma associated with mental health conditions and to expand access to mental health care.

NOTE: The above link is available to National Law Journal subscribers.

Two class actions pertaining to TMS, one with Cigna and the other with Aetna, have received class certification orders.

Weil v. Cigna Health et al. received preliminary approval of class action settlement and related relief by the United States District Court for the Central District of California on April 17, 2017.

Meidl v. Aetna et al. was certified as a class action by the United States District Court for the District of Connecticut on May 4, 2017.

Each named plaintiff alleges that their respective health insurance company has categorically refused to cover Transcranial Magnetic Stimulation (“TMS”), a safe and effective treatment approved by the U.S. Food and Drug Administration. In 2008, the FDA cleared TMS for patients who have failed to respond to psychotropic medications. Unlike electroshock therapy, TMS is performed on an outpatient basis without sedation and does not typically result in side effects such as memory loss.

“These class certification orders are significant because without them, few, if any, patients would have the financial or emotional resources to pursue this type of misconduct individually,” said Psych-Appeal’s Meiram Bendat.

Psych-Appeal co-filed both the Aetna and Cigna TMS class actions.

Related coverage:

Aetna Facing Class Action Over Depression Treatment Coverage, Bloomberg Law, May 5, 2017

Cigna Ends Depression Treatment Lawsuit With $2.75M Payment, Bloomberg Law, March 22, 2017