Insight Matters
Winter 2005

Denials of Coverage Investigated
By Brooke Wolf, M.D., Chair, Psychiatric Practice Committee

As chairman of the Psychiatric Practice Committee of the OPA, I wish to report the efforts that are underway to address concerns that psychiatric patients in Ohio are being denied access to their health insurance benefits when in need of inpatient psychiatric care. The Cleveland Psychiatric Society (CPS) began an initiative on July 28, 2004, when representatives met with Ann Womer Benjamin, the Insurance Commissioner of Ohio. Members discussed concerns that some insurance companies are not living up to their own criteria for medical necessity in approving inpatient stays. This group also made Commissioner Womer Benjamin aware that review and appeals procedures of some companies do not live up to the standards set by the Patient Protection Act of 1999. Some companies show a consistent pattern of denying coverage for inpatient days by using unreasonably narrow criteria for medical necessity, forcing doctors and hospitals to expend time and energy in lengthy appeals. Denial reasons given by some companies do not give specific criteria as to why the care was denied. The process of how to appeal for an external review is not clearly specified in the denial letters of some companies. As a result of these roadblocks and general feelings that psychiatrists are powerless to fight the forces of insurance companies, only three cases involving psychiatric denial of care had been brought for external review in Ohio as of July, 2004.

On January 10, 2005, Commissioner Womer Benjamin met with the CPS. Specific data was presented, giving ratios of approved days to total days by insurance company for 2003. Concerns were raised about unfair review and appeals processes of some insurance companies. Following this meeting, I received a letter from Susan Stead, Assistant Director of Investigations and Licensing Services of the Ohio Department of Insurance (ODI), stating that ODI "will undertake a review of certain health insurance benefits and claims practices."

Ohio psychiatrists now have a window of opportunity to have our concerns addressed. Therefore, I am urging all psychiatrists to obtain patient permission and to appeal all unreasonably denied cases through both internal and external review. Insurance companies must bear the entire cost of external reviews. Families of patients whose care has been inappropriately denied should also be encouraged to write complaint letters to:

Susan Stead, Assistant Director
Office of Investigative & Licensing Services
Ohio Department of Insurance
2100 Stella Court
Columbus, OH 43215-1067

The OPA Practice Committee is currently collecting data from all hospitals, giving the ratio of denied days to total days by insurance company per year. This data will be used to show the Insurance Commissioner statewide trends in denials by various insurers. Psychiatrists are urged to solicit letters of support for this investigation from physicians of other specialties, from other specialty societies and from hospital CEO's. We are encouraged to know that Commissioner Womer Benjamin does have the power to investigate, fine and take further action to enforce regulation of health insurance companies to assure that their business practices are fair and in good faith with their providers and subscribers.

The Psychiatric Practice Committee would appreciate being copied on any letters of support for this investigation. Letters may be mailed to the OPA office.
Additional information on consumer and provider complaints may be found on the ODI's website at www.ohioinsurance.gov.

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