Massachusetts Neuropsychological Society

Transcription

1 Massachusetts Neuropsychological Society April 26, 2011 Office of the Attorney General of Massachusetts Assistant Attorney General Thomas M. O'Brien (Chief, Health Care Division) Assistant Attorney General Susan E. Brown 1 Ashburton Place Boston, MA Dear Assistant Attorneys General O Brien and Brown: We are writing to follow up on a meeting held in your offices on June 15, At that meeting, representatives of the Massachusetts Neuropsychological Society (MNS) and the Massachusetts Psychological Association (MPA) brought to your attention some changes that Blue Cross/Blue Shield of Massachusetts (BCBSMA) implemented to manage medical benefits, including neuropsychological services, beginning in May Providers of neuropsychological services are now required to submit written requests for authorization of the service requested and the number of hours estimated to be required to complete the evaluation. BCBSMA approves these requests based upon the McKesson/InterQual criteria set, a product which BCBSMA purchased from a healthcare information technology company called the McKesson Corporation. These criteria use patients diagnoses and ages to limit the hours granted for an evaluation. In addition to these criteria, BCBSMA has adopted additional policies and procedures that affect authorization, review, adverse determination, and reimbursement of neuropsychological and psychological assessment. It is our position that BCBSMA uses these management procedures in a manner that systematically denies access to medically-necessary care for their subscribers, violating Massachusetts statutes and regulations in a number of respects. Moreover, BCBSMA case managers often do not even follow their own criteria and review process, further blocking or delaying their subscribers from accessing proper and necessary treatment. At the conclusion of our meeting, Attorneys O Brien and Brown asked us to provide cases that illustrated our concerns regarding violations of Massachusetts law. We have gathered a number of examples and will summarize these as well as the concerns we are presenting for your consideration. Our concerns include some new issues that have arisen since our meeting. The case material and supporting documents are included in the attached appendices. First, you will find a summary of the authorization, appeals, and reimbursement process,

2 Page 2 of 5 together with specific examples of statutory violations occurring at each stage and how these problems impact consumers. You will also find three in-depth examples of individual cases that exemplify these violations of Massachusetts law; in all examples, citizens of the Commonwealth sustained substantial harm because of BCBSMA s policies, procedures, and actions. We then provide a larger series of additional cases illustrating various failures of the BCBSMA authorization process. Consumers are harmed when They are inadvertently treated for the wrong condition when authorization for appropriate neuropsychological and psychological assessment is denied, or when the time authorized is insufficient for a particular patient given his/her symptoms and circumstances. Neuropsychological and psychological assessments are often used to differentiate amongst multiple possible diagnoses, to identify symptoms that will respond to treatment, and to guide pharmacological and other interventions. Referring providers often request evaluations when they conclude that they need more information to guide their treatment decisions. When BCBSMA hinders the proper evaluation, the referring doctor must make treatment decisions based upon incomplete or even erroneous-- information. This can be dangerous because some medications used to treat certain neurological and psychiatric conditions can have severe adverse effects in patients with other conditions. (For example, a stimulant used to treat Attention Deficit/Hyperactivity Disorder could induce anxiety, tics, or hallucinations in vulnerable individuals who may actually have attention problems for other reasons.) In addition to the risk of administering incorrect medications, other consequences of inappropriate treatments may include unnecessary, expensive, and potentially-harmful procedures such as psychiatric hospitalizations, nursing-home commitments, or ongoing nonpharmacological treatments. Patient evaluation and treatment is delayed because authorizations for requested services are systematically insufficient, and the only recourse is a prolonged appeals process. Most of our patients are referred by their primary care doctor, neurologist, psychiatrist, rehabilitation medicine physician, or psychotherapist for evaluation. The purpose is to clarify the diagnosis, plan an effective course of treatment, and institute appropriate supports to help a patient with daily activities. When BCBSMA case managers do not respond to authorization requests in a timely fashion, or when certain services are systematically denied without consideration of a patient s individual case, proper treatment is blocked or delayed. During the appeal process, which may take weeks, even if the consumer and provider eventually win, the patient continues to suffer impairment at home, at work, and in the community. Their disabilities and other individual differences are not taken into account in managing their care. We understand that the McKesson/InterQual criteria were designed to be used as a general guideline for the appropriate amount of testing in the average case a starting point to be adjusted for the unique circumstances of the patient. BCBSMA uses them instead as hard, unalterable criteria. This means that consumers neuropsychological services are being limited by criteria not designed to provide the final answer, and thus not valid for that use. This is a particular problem when BCBSMA uses this cookie-cutter set of criteria to authorize or deny treatment based arbitrarily upon a single one of the diagnoses listed in the authorization request, while ignoring detailed information about the patient such as other possible diagnoses that may affect the patient s performance. For example, as a

3 Page 3 of 5 result of their neurological conditions, some individuals process information more slowly, have difficulty forming their thoughts into words, and/or move more slowly. These symptoms can substantially increase the time required to interview and test the patients in order to arrive at a diagnosis and recommendations, but BCBSMA case managers indiscriminately apply the McKesson/InterQual criteria for the number of hours approved for a given diagnosis, often failing to make reasonable accommodations based on the patient s presentation and needs. That failure to make appropriate accommodations may constitute a violation of the Americans with Disabilities Act of 1990, 42 U.S.C. Sections et seq.; we ask that your office investigate this. Furthermore, it is common for patients to have multiple neurological/ psychological conditions, which complicates their presentation and the assessment, but the McKesson/InterQual criteria are not designed to address co-existing conditions. Consumers are treated as their diagnosis instead of as individuals with their particular circumstances taken into account. A diagnosis alone is often not enough to determine a successful treatment plan. Some patients are referred for testing when their diagnosis is already known because they are not responding to the prescribed treatment; further clarification of their diagnostic picture is required to make appropriate treatment recommendations. Also, different patients with the same diagnosis often have different symptoms as a result of their condition. For example, a patient may have been accurately diagnosed with a traumatic brain injury. Despite this diagnosis, however, the patient, health care providers, and family members may still not understand why the patient is having difficulty understanding what others are saying to him or her, demonstrating safety awareness, or engaging in effective problem-solving and decision-making. Neuropsychological evaluation can help to identify the specific reasons why an individual experiences such difficulties, together with individualized solutions to best address the patient s symptoms and functional difficulties. When insurance coverage for a procedure is predicated upon a diagnostic label and an assumption that all patients with that label have the same difficulties, it does not take into account the individual s unique pattern of strengths and cognitive impairments, the severity of the individual s symptoms, the individual s psychosocial environment, the daily tasks expected of that individual, and the factors that may be getting in the way of effective treatment. Consumers are not warned that their neuropsychological assessment coverage is subject to the hidden limitation of the criteria. BCBSMA promises consumers broad medical coverage, subject to its medical necessity requirement that takes into account the individual needs of the patient. It is our understanding that the company s benefits booklet and other marketing materials do not warn consumers that their actual coverage for neuropsychological services may be arbitrarily and severely limited by the McKesson/InterQual criteria or by other limitations in ways that do not account for the consumer s actual condition and needs. Additionally, some of our members have advised us that BCBSMA made denials of coverage based upon a lifetime limit of three evaluations. When services are deemed non-covered, consumers may then be forced to pay out of pocket for services that fall within the broad promise of coverage. This leads many patients to simply forgo their assessment and treatment during difficult economic times, which may in turn increase their costs for medical care in the future. Consumers are required to engage in time-consuming appeal processes that they may not have the capacity to understand. Many of our consumers, by the nature of our profession, are vulnerable

4 Page 4 of 5 and are hindered in advocating for themselves because cognitive impairments affect their ability to understand the process, to organize a coherent, detailed written response, or to remember the sequence of steps they need to take to complete the process. Families and caregivers who are overwhelmed by the appeals process are prone to give up, to their own detriment. The financial cost of an appeal (albeit relatively small), and the additional delay in initiating services, deters consumers from pursuing an external appeal. (Because a psychologist generally cannot perform an incomplete evaluation due to ethical obligations, the evaluation typically cannot be started until it is clear whether the entire service will be covered.) Changes in plans are made in the middle of a plan year, affecting the subscribers ability to access the services promised in their plan. For example, the coinsurance that individuals on a BCBSMA PPO plan are required to pay increased substantially mid-year because BCBSMA abruptly lowered the rate at which they reimburse out-of-network providers. Instead of simply paying their coinsurance, subscribers now are required to pay the out-of-network provider s full fee up front and be reimbursed directly by BCBSMA at the in-network rates. This constitutes a financial hardship for many people. PPO subscribers pay a higher premium for the option of receiving services from a larger provider group who may be out-of-network. We believe that this is a classic bait-and-switch scenario: the consumer signs up for a plan that is more beneficial financially, only to have the company switch them to less favorable terms in the middle of the plan year. Patients tell us they received no warning about the change in how out-of network-providers are reimbursed and the amount they are required to pay, disrupting services for those who experience this as a financial hardship. Their providers have difficulty remaining in-network because of large and abrupt changes in provider reimbursement, increased and uncompensated administrative burden, and lack of clear communication from BCBSMA. Many providers are essentially small-business owners who struggle to maintain their practices when reimbursement rates decline while required administrative expenses increase. BCBSMA s new authorization procedures take many additional hours per patient of the provider s time. Since these tasks cannot be delegated to support staff, the time available for patient care is reduced. Last autumn, we heard from a number of members of our organizations that they are unable to afford remaining in-network for BCBSMA after an imposed decrease of nearly 40% in the reimbursement for neuropsychological assessment, implemented on 09/01/2010 with less than one month s notice. When the pool of in-network providers declines, it increases the waiting time for referrals and hinders consumer choice as well as the ability to access proper services. Consumers are faced with longer wait times and may have to travel longer distances to access a provider in their insurer s network. In some (e.g., rural) areas of the state, where there may be fewer providers per capita, these distances are prohibitive to many consumers who are paying a high premium for benefits that they have difficulty accessing when the need arises. We appreciate that insurance carriers are under tremendous pressure to reduce costs, and we support responsible practices in medical decision-making that will help carriers and providers to make the best use of resources. However, what we see, and what we hear from our colleagues, indicates that these recent BCBSMA policy and procedural changes detrimentally affect care for some of the Commonwealth s most vulnerable citizens. Moreover, as noted above, inadequate neuropsychological assessment may increase costs over the long term because the appropriate course of treatment is not pursued and/or the patient is subjected to unnecessary or even harmful treatment.

5 Letter to Thomas M. O'Brien, Assistant Attorney General, MA Page 5of5 In the attached Appendices, you will find supporting material, including: 1. A "walkthrough" of the authorization, appeals, and denial process, together with information about suspected violations of Commonwealth statutes at each step of the process and how these violations may be harmful to consumers (Appendix A). 2. Three representative cases demonstrating how consumers were adversely affected when services were denied or limited, including: a. a 56-year-old woman who lost her job (and health insurance) as a result of her cognitive difficulties while waiting to get approval for neuropsychological testing. (Appendix B) b. a middle-schooler who had been misdiagnosed with a learning disability when she actually required treatment for anxiety and attention problems, and whose family had to pay out-ofpocket for the evaluation when BCBSMA denied all neuropsychological services. (Appendix C) c. a 7-year-old child with memory impairment, behavior problems, and delayed reasoning skills whose family opted not to pursue evaluation after BCBSMA denied all services. (Appendix D) 3. A larger set of cases illustrating problems with the authorization process that prevent consumers from getting medically-necessary care and thereby cause them harm. (Appendix E; Cases 1-23) We would be pleased to provide further assistance, clarification, or documentation to the Attorney-General's Office. Please do not hesitate to contact us if we can provide additional information to support your investigation. Very sincerely yours, Elena J. Eisman, Ed.D., ABPP,. Executive Director Massachusetts Psychological Association The Massachusetts Psychological Association is the 501 c-6 non-profit organization representing psychologists in Massachusetts. With 1800 members, its purpose is to advance psychology as a science, as a profession, and as a means ofpromoting human welfare. 5w n244 5t. o48e eai Sandra Shaheen, Ph.D., ABPdN, President Massachusetts Neuropsychological Society The Massachusetts Neuropsychological Society is a 501c3 non-profit organization founded in 1988 for educational, scientific, literary and charitable purposes, particularly to promote research, service and education in neuropsychology. MNS currently represents more than 300 members. Katherine C. Nordal, Ph.D., Executive Director American Psychological Association, Practice Directorate The American Psychological Association (APA) is a scientific and professional organization that represents psychology in the United States. With more than 154,000 members, APA is the largest association ofpsychologists worldwide. cc: Matt Selig, J.D., Executive Director, Health Law Advocates, Eric Harris Ed.D, J.D., and Robin Johnson, J.D.