Insight Matters
Spring 2005

OPA Proactive in Addressing Managed Care Concerns

Brooke Wolf, M.D., Chair, Psychiatric Practice Committee

The OPA Practice Committee is focussed on solving problems in three main areas of psychiatrist and patient distress over some managed care company policies. The first two areas of distress, unreasonable medical necessity denials for payment of inpatient psychiatric care and unfair review practices, have driven many private practice psychiatrists out of inpatient work, have limited patient access to their benefits and continue to shift an extra burden of patient care to the already overburdened state mental health system. The following efforts of our committee are underway:
" We continue to monitor and encourage the investigation of managed care companies by the Ohio Department of Insurance (ODI). Melissa Hall, Chief Investigator of the ODI, who has replaced Susan Stead, has informed the OPA that insurers have been notified of the investigation.

• We are still encouraging psychiatrists, hospitals and patients to send documentation of egregious cases in which payment for inpatient care has been inappropriately denied to the ODI.
• We recommend patients be asked to sign a form at the time of inpatient admission, giving the doctor or hospital permission to pursue both internal and external reviews of any denied days. We encourage appealing all cases with merit through both internal and external reviews.
• The third area of distress over managed care company policies concerns their unreasonably low fees for mental health services. These fees are reducing the quality of patient care by pushing psychiatrists to see patients for shorter lengths of time to meet their escalating expenses.
• We are concerned that fees set by managed care companies are 70-80% below relative value units established yearly by the federal government as the standard on which Medicare fees are based. Psychiatrists in private practice are not really free to join or not to join panels because these panels have captured such a large market share in many areas. We are investigating what can be done to correct this unjust situation, including the viability of a legal approach.
• We are gathering information about the lawsuit in Cincinnati in which major health insurance companies, including Humana, Aetna and United Healthcare, were successfully sued for fee-related issues and for stated usual and customary fees not being obtained by any actual survey of physician fees in the area, but rather with benefit of some knowledge of what other companies in the area were going to charge. This lawsuit may provide a precedent for future suits in other areas of the state and even the nation.
• We plan networking efforts with the Ohio State Medical Association and associations of mental health professionals to develop joint efforts to address these grievances.

Issues for future efforts include continuing the fight for meaningful mental health parity and monitoring of managed care companies to assure that their policies do not compromise adequate patient care. Members who have suggestions about how to address these problems are encouraged to forward all suggestions to the OPA Practice Committee.

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