Illinois group sees ‘red flags’ in denial of mental-health payments

September 19, 2017 | By Dean Olsen

Frequent denials of payment for substance-abuse and mental-health services in Illinois are creating unnecessary barriers to treatment despite an ongoing opioid crisis, a report released Tuesday says.

“This raises a lot of red flags,” Kelly O’Brien, executive director of The Kennedy Forum Illinois, said during a news conference. The not-for-profit group released the 16-page report with partners that included the Illinois Association for Behavioral Health and the Illinois Health and Hospital Association.

Three out of four treatment providers responding to the non-scientific survey in late 2016 and early 2017 said managed-care companies serving patients on Medicaid denied paying for a range of services either sometimes, often or always.

About 60 percent of those providers said Medicaid managed-care companies always or often denied payment for inpatient treatment.

And when patients were covered by private, commercial insurance plans, nearly half of the plans denied coverage for inpatient mental health and addiction at least sometimes, according to the treatment providers.

“It is important to note that there can be valid reasons why payment for mental health or addiction care is denied,” the report says. “However, providers indicated that they frequently encounter barriers to payment.”

The denials by publicly and privately funded insurers can result in services being delayed, denied or offered for fewer days or weeks even when evidence indicates longer treatments are more effective, according to treatment advocates.

“It is just not seen as an emergency, unlike heart disease,” Thomas Britton, president and chief executive officer of Chicago-based Gateway Foundation, said at the news conference. Gateway also operates an inpatient and outpatient treatment center in Springfield.

People with substance abuse often are dealing with mental illness, and people with mental illness often struggle with drug addiction at the same time, experts say.

Joanna Dailidas, a former Lake Zurich resident now living in Florida, said during the news conference that her son, Joey Dailidas, committed suicide at age 24 one year ago in Chicago after she and her husband were frustrated by years of battles with an insurance company to get him adequate mental-health treatment.

“My son died fighting a battle he couldn’t win,” Joanna Dailidas said.

The Kennedy Forum survey report didn’t conclude whether Illinois insurers were violating state and federal “parity” laws. Those laws say that people needing mental-health and addiction-treatment treatment shouldn’t face more coverage limitations than people with other types of medical conditions. Violation of the laws can lead to fines.

But a lack of parity has been found elsewhere in the country, the report said. The National Alliance on Mental Illness, for example, found that patients seeking coverage from private insurers for mental-health services were denied “at a rate double those seeking coverage for other medical services,” according to the report.

The survey of Illinois treatment providers was based on self-reported data from 193 organizations out of 1,331 — a 15 percent response rate — so the poll isn’t necessarily representative of all providers in the state.

But David Lloyd, policy director of Kennedy Forum Illinois — founded by former Rhode Island Congressman Patrick Kennedy — said many of the responders were large providers of care.

The survey results, Lloyd said, are a “valuable starting point” for improving care for people who deserve treatment for their mental-health issues just as much as people with heart disease.

In the report, the Kennedy Forum called for more aggressive oversight by governmental insurance regulators to review payment denial rates and other barriers to care.

Forum officials also said health plans should do internal analyses, state lawmakers should pass laws requiring more transparency by those plans, and consumers should file appeals when there are denials or restrictions.

Regardless of current coverage problems in Illinois, Forum officials said proposals in Congress to repeal and replace the Affordable Care Act and roll back the expansion of Medicaid programs in states such as Illinois would decrease access to mental-health and addiction treatment services.

The report prompted state Rep. Deb Conroy, D-Villa Park, chairwoman of the House Mental Health Committee, to say she would hold hearings on the issues raised.

“The General Assembly must get the bottom of these reported barriers to mental health and addiction coverage,” Conroy said in a news release.

State Rep. Steve Andersson, R-Geneva, said in the release that he filed House Resolution 607 “to formulate a plan to remove barriers to mental health and addiction coverage and improve coverage parity.”

When asked to comment on the report, Colleen Miller, spokeswoman for Blue Cross and Blue Shield of Illinois, the state’s largest private insurance company, would say only that the company “is committed to providing our members with access to high-quality medical and behavioral-health care.”

Illinois Attorney General Lisa Madigan said in a statement that the report “raises important questions” about access to care. Anyone having problems with their private insurance coverage, she said, should contact her office’s Health Care Bureau at (877) 305-5145.

People in Medicaid managed-care plans who are having access problems should contact the Illinois Department of Healthcare and Family Services, Kennedy Forum officials said.

HFS spokesman John Hoffman said the department, through its planned “reboot” of the state’s Medicaid managed-care program in 2018, is putting “significant emphasis on behavioral health.”

“Parity language to secure this care will be included in the new (managed-care) contracts,” Hoffman said. He added that managed-care companies in the new system “will be required to provide the necessary documentation, reporting and analyses to establish and demonstrate compliance. HFS welcomes focus and input on this vital issue.”

Consumers can call the Illinois Department of Insurance at (866) 445-5364 for assistance, department spokesman Michael Batkins said. “Families dealing with mental-health issues and substance-use disorder deserve support and understanding,” he said.

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