Blue Cross & Blue Shield of Rhode Island has been improperly denying claims for mental health and addiction treatment, according to the results of an examination by the state Office of the Health Insurance Commissioner (OHIC).
Rhode Island’s largest health insurer’s process of reviewing claims resulted in “clinically inappropriate” denials of coverage in violation of state and federal laws, the report said.
The 38-page report follows an examination by OHIC launched in 2015, of more than 400 randomly selected cases, mostly from 2014. The examiners looked at whether the state’s four largest insurers are providing “parity” for mental health coverage.
State and federal laws require health insurance plans to provide coverage of mental health and substance-use disorders under the same terms and conditions as coverage for other illnesses and diseases.
OHIC’s report describes Blue Cross’s process for approving coverage, known as utilization review, as lacking adequate documentation or consistency, with different conclusions based on similar facts depending on which staffer conducted the review. Blue Cross’ review procedures were “unreasonable and inequitable,” the report said, and they “did not properly consider patients’ welfare and safety.”
In one case, the report said, Blue Cross denied the prescribed doses of Suboxone, for a patient being treated for opioid addiction. Suboxone is the brand name for buprenorphine, a medication which blunts opioid cravings.
Blue Cross’ practices for requiring prior-authorization of prescription drugs used to treat mental health conditions, the report said, in some cases impeded or delayed care.
In May 2017, Rhode Island’s four major insurers agreed to end the practice of requiring prior authorizations for medications, such as buprenorphine, to treat opioid addiction.
OHIC’s report includes recommended corrective actions, and orders Blue Cross to submit a proposed plan to address the problems by Sept. 28. OHIC also has ordered Blue Cross to “discontinue its utilization review program for in-network behavioral health services…”
Blue Cross was using ValueOptions for its utilization reviews in 2014, the report said, when most of the cases were reviewed. Beacon Health Options, a Boston-based company formed by a merger between ValueOptions and Beacon Health Strategies, currently administers Blue Cross’ review for mental health services. “At all times,” the report siad, “Blue Cross remained fully responsible for compliance with state and federal laws and regulations.”
In lieu of a penalty, Blue Cross has agreed to contribute $5 million over the next five years to a new state fund to improve access to mental health care. The contribution was announced by OHIC on Sept. 5, prior to the release of its examination report.
The report acknowledges that Blue Cross was cooperative with the examination and “offered innovative solutions in response to the examination’s findings.”
As of January 2019, the report said, all health plans will adjust the co-payments charged to patients for behavioral health counseling and medication maintenance to be more affordable, and comparable to primary care visits.
