MICHAEL A. GOLDBERG, PH.D. Director of Professional Affairs 189 Access Road, Second Floor Weymouth, MA

Transcription

1 MICHAEL A. GOLDBERG, PH.D. Director of Professional Affairs 189 Access Road, Second Floor Weymouth, MA t: , ext 208 f: MAIN OFFICE 195 Worcester St, Ste. 303 Wellesley, MA t: f: Kevin Beagan Deputy Commissioner, Health Care Access Bureau Massachusetts Division of Insurance 1000 Washington Street, Suite 810 Boston, MA Nancy Schwartz Director, Bureau of Managed Care Massachusetts Division of Insurance 1000 Washington Street, Suite 810 Boston, MA October 31, 2014 Dear Deputy Commissioner Beagan and Director Schwartz: There are over 5000 licensed psychologists in Massachusetts who serve children, adults, and the elderly in every Massachusetts community. The Massachusetts Psychological Association (MPA) is the largest organization of psychologists in the Commonwealth. The mission of MPA includes advancing psychology as a means of promoting human welfare. We appreciate the opportunity to have participated in the two recent listening sessions that you held regarding neuropsychological testing. While we support the overwhelming need to control health care costs, protecting consumers access to appropriate health care services is more critical than ever in the context of healthcare reform. As you requested, we are providing written follow up comments herein. Health care payment reform has placed more responsibility and risk for primary care providers to address the overall health care of our citizens. Primary care providers who have ongoing relationships with their patients value behavioral health services, including psychological and neuropsychological assessment. PCPs increasingly understand that relying solely on self report interview data often fails to result in the most reliable, valid and useful diagnosis and treatment plans and that treating patients without such guidance often has negative consequences, including wasted resources related to providing inappropriate treatment for complex cases. This understanding is consistent with conclusions made by an Expert Consensus Panel for the National Institute of Mental Health that neuropsychological and psychological testing often provides the most comprehensive and valid assessment for various mental and physical conditions. Increasing access to appropriate use of psychological and neuropsychological testing will

2 support health care reform initiatives to increase the role of primary care providers in managing the health of their patients and integrating behavioral health services for effectively into primary care systems. Inclusion of Psychological Testing and Assessment in Scope of Initiative Psychologists provide psychological and neuropsychological assessment and testing services that are similar but somewhat different in focus. However, many of the problems for consumers accessing services are the same. We suspect your focus on neuropsychological testing alone was an inadvertent oversight and request that you expand this initiative to include psychological assessment and testing. Global Access Problem Accessing psychological and neuropsychological testing from fully insured Massachusetts Health Plans is very difficult and is associated with extraordinarily frequent adverse determinations. We believe that comments made by the representative of the Massachusetts Association of Health Plans at the last meeting suggesting that an unscientific survey of their members did not find a problem for consumers accessing testing services is invalid, and that the report of the Health Law Advocates dated October 21, 2014 more accurately reflects consumers experience. Health plans should be required to routinely and reliably report all data regarding the number and frequency of adverse determinations for psychological and neuropsychological assessment/testing and such data should be made available to the public. Health should be made to understand that denial of any units requested by a provider represents an adverse determination. Medical Necessity Criteria Consumers have difficulty accessing what we believe is coverage for scientifically based services that are commonly accepted by the health care community knowledgeable about these services because of inappropriate medical necessity criteria. Actionable Recommendations: We urge the DOI not force collaboration among the health plans to set uniform medical necessity criteria in a manner that results in inclusion of the least scientifically valid and least accepted practices of each health plan. Regulation or legislation that allows consumer groups and professional societies to challenge medical necessity criteria in general without having to include a specific consumer. Expanding transparency regulations and laws to require health plans to provide consumers and providers with details on how medical necessity criteria where developed including but not limited to the following: o Where they were developed o By whom, including licensure and credentials. o What was the specific role of those involved in development including whether they actually review and approved of the criteria. PAGE 2 OF 6

3 Modification of regulations and statues that set a standard for what is acceptable by the health care community that requires more meaningful participation of providers with such services within their scope of practice and competence beyond perfunctory and often meaningless consultation, such as requiring approval by individuals or bodies that commonly perform the service for which they are setting criteria. Application of Medical Necessity Criteria/Utilization Management Requests for Irrelevant Information: Some health routinely request information subsequent to the submission of the prior authorization that do not seemingly address scientifically valid medical necessity criteria that are acceptable amongst the local and national health care community with the proper expertise to understand the use of neuropsychological and psychological testing. Examples of these requests include complete medical records to which the requesting provider does not have easy access. We believe that these requests serve bypass regulatorily required response times and function to increase obstacles for consumers to obtain access to services while increasing uncompensated costs for providers. Regulation or legislation that specifically prohibits health plans from requiring information that does not specifically address valid medical necessity criteria and a mechanism for providers and consumers to lodge complaints about this conduct that results in enforcement. Inadequate Notice of Adverse Determinations: 211 CMR (6) states the following: (6) Written Notice. The written notification of an adverse determination shall include a substantive clinical justification that is consistent with generally accepted principles of professional medical practice, and shall, at a minimum: (a) identify the specific information upon which the adverse determination was based; (b) discuss the insured's presenting symptoms or condition, diagnosis and treatment interventions and the specific reasons such medical evidence fails to meet the relevant medical review criteria; (c) specify any alternative treatment option offered by the carrier, if any; (d) reference and include applicable clinical practice guidelines and review criteria; and (e) include a clear, concise and complete description of the carrier s formal internal grievance Written adverse determinations issued by health plans for psychological and neuropsychological assessment services routinely do not comply with this regulation. This undermines consumers ability to request reconsideration and prepare for an external appeal. Likewise, failing to holding health plans accountable to this mandate enables them to issue determinations without the careful review of the case required to comply which undermines a fair and valid utilization management process. PAGE 3 OF 6

4 Enforcement actions to ensure that health plans are providing the required information in notices of adverse determinations. Adverse Determinations Rendered by Providers without Psychological & Neuropsychological Testing in their Scope of Practice or Competence Some health plans routinely issue adverse determinations for neuropsychological and psychological assessment services that include testing procedures by providers other than licensed psychologists. 211 CMR (c) explicitly states that adverse determinations shall be made by a person licensed in the appropriate specialty related to such health service and, where applicable, by a provider in the same licensure category as the ordering provider. Likewise, we call your attention to the definition of Same or Similar Specialty on page 8 of 211 CMR that states the provider should been one who typically provides the service under review. It is our understanding that any adverse determination for psychological or neuropsychological assessment must be issued by licensed psychologist who typically provides these specific services for the condition that is the subject of the review. We believe that a licensed provider issuing an adverse determination for a population or condition that they are not adequately trained to work with is also likely to be considered a violation of licensing regulations. At the last listening session you asked for us to inform you of the specific health plans that routinely use non-psychologists to issue adverse determinations for psychological and neuropsychological testing. As per your request, please be aware that Tufts Health Plan is one such plan that routinely violates this mandate. Clear processes for complaint and enforcement of these regulations. Appeals Process Is Too Difficult for Consumers Most consumers who receive adverse determinations for testing services are unwilling or unable to go through the arduous task of seeking external appeals. Given the high demand for these services providers are not motivated to provide the uncompensated time to help consumers file appeals. Provider and consumer reconsideration requests are very useful in remedying many inappropriate adverse determinations and eliciting information from health plans that is useful in preparing for appeals. Actionable Recommendations: Maintain and enforce regulations that mandate timely reconsideration of adverse determinations. Regulation or legislation that requires health plans to include information about their rights for reconsider requests in their adverse determinations notices. Provider Reimbursement Policies PAGE 4 OF 6

5 Health plan reimbursement policies for neuropsychological and psychological testing services typically do not reflect the immense demand for these services, the costs related to training and education as well as equipment and other practice related costs. We are concerned that health plan policies for setting fees for all behavioral health services, including testing services, may represent violations of mental health parity laws. Given the poor reimbursement, time consuming and frustrating utilization management practices used by health plans and the immense demand for these services the percentage of providers who provide these services who refuse to contract with health plans is extraordinary. Thus consumers who are willing and able to pay for these services without using their health plan can access services much easier than consumers who must rely on their health plan. Investigation and enforcement action to ensure that health plans are complying with state and federal parity laws and are setting rates for these services consistent with how they set rates for most medical/surgical benefits. Limited Provider Networks We believe that pervasive health plan desire to limit access to neuropsychological and psychological testing services and the resulting payment and utilization management policies detailed elsewhere herein, along with the immense demand for these services results in a) health plans limiting the number of providers who provide these services in the networks and b) providers being unwilling to contract with health plans. Requiring health plans to routinely report the number of network providers in various geographical areas who a) provide psychological and neuropsychological testing; b) specifically for pediatric, adult and geriatric consumers and c) whether or not they are accepting new patients and to make that data available to the public. Different Deductibles and Copayments Consumers experience immense frustration related to deductible and copayments because a) copayments and deductibles vary immensely from plan to plan within and between health plans based on diagnosis and/or whether it is considered treatment or assessment and b) health plans representatives themselves are unable to understand and communicate benefit information to consumers and providers reliably. This undermines consumers abilities to understand and utilize their benefits and often results in unexpected financial responsibility. Actionable Recommendations: Regulation or legislation requiring health plans to have the same copayment and deductibles for all services provided by behavioral health providers (e.g., Psychologists, Psychiatrists, Social Workers, Psychiatric Nurses, and Licensed Counselors) regardless of whether the procedure coded is primarily a treatment code or testing code and regardless of whether the diagnosis is deemed psychiatric or non-psychiatric. PAGE 5 OF 6

6 Regulation or legislation, consistent with current unfair and deceitful business act laws, that hold health plans accountable and give consumers recourse when they provide inaccurate information to consumers and providers that have negative consequences. Appropriate Representation of Science and Practice in Health Plan Leadership In addition, we believe that the difficulties that health plans have establishing and implementing policies and procedures that are most consistent with scientific evidence regarding behavioral health assessment and treatment are negatively impacted by a pervasive lack of involvement of non-physician providers in the behavioral health leadership of behavioral health plans. The majority of behavioral health care in the commonwealth is provided by non-physicians. Nearly all of the science and practice of psychological and neuropsychological assessment are conducted by psychologists. Likewise, behavioral health science is clear and consistent in its conclusions that medication alone is rarely the best treatment in the short-term nor the long-term for any behavioral health condition. Having psychologists and other non-physician providers who are trained in the scientific methods and who have competence to provide the services that they are managing will help us advance the delivery of behavioral health services in ways that are most valid, most effective and most cost effective. Regrettably we have no clear recommendation for the Department of Insurance in this regard at this time. We understand that the many of the recommendations herein may be beyond the scope of your particular bureau. However, solving these problems will require more effective collaboration between multiple state agencies and we hope that these comprehensive recommendations can be used in that context. Respectfully, Michael A. Goldberg, Ph.D. Director of Professional Affairs PAGE 6 OF 6