Talk to people involved the mental health system and it won't be long before you hear complaints about the difficulty of getting private insurance to pay for mental health services.
Some advocates say the answer is to better enforce state and federal laws requiring equal coverage for mental health and medical services. Some clinicians and lawmakers want the state to take over insurance coverage for mental health care, billing insurance carriers for the cost.
The Connecticut Insurance Department has another approach: Help patients get the right paperwork to their carriers, to avoid problems that can lead to claims being denied.
The department is working with psychiatrists at the UConn Health Center to develop a plain-language guide for consumers and behavioral health providers to make it clear what they'll need to submit to get insurance coverage. The "claims tool kit" is expected to be completed this summer, and is intended to help people get their claims approved on the first try.
Gov. Dannel P. Malloy, in a statement, called it "a common-sense approach to what can be a profoundly frustrating process."
The effort originated last summer, when insurance department officials began looking into disparities between insurance carriers in denial rates for behavioral health claims.
Many people have raised concerns that insurers aren't complying with state and federal parity laws, which prohibit insurers from placing restrictions on mental health or substance abuse services that don't apply to medical services, or that regulators aren't enforcing them.
But Deputy Insurance Commissioner Anne Melissa Dowling said many of the problems getting insurers to pay for services appear to stem from issues in the claims process, including incomplete information, coding errors or documentation problems.
"A lot of things, we think, that have been chalked up to noncompliance with parity are not really that," Dowling said. "We think a lot of it is procedural."
One problem: Many behavioral health providers aren't part of insurance company networks. That means they take payment from patients directly, leaving the patients and their families to try to get reimbursement from the insurance carrier. By contrast, most medical providers participate in insurers' networks, so patients don't have to deal with insurance billing issues.
Another challenge: With mental health issues, it's not always clear-cut what the appropriate treatment is.
"If you break your leg, you repair it, cast it and send it off," Dowling said. "Behavioral health and mental health, there are many different approaches depending on the individual, and so it's not quite as straightforward."
That leaves patients or their families to compile information so they can get paid back, often without a clear sense of what's needed, at a time when they're already facing the strain of a mental health crisis.
"We just think that's way too much stress for them to bear," Dowling said.
Dowling said the hope is that insurance carriers will be persuaded to use the tool kit as the standard for what's required to get claims covered.
Dr. Ted Lawlor, who is working on the tool kit and is clinical chief of the UConn Health Center's psychiatry department, said the idea is to create plain-language instructions for patients and providers so it's clear what information they must submit to insurance companies to get claims approved the first time.
Critical to that process, Lawlor said, will be having access to the criteria insurers use in determining what services are medically necessary.
"If you don't know what they want beforehand, then in some ways you're shooting in the dark," he said.
State Healthcare Advocate Victoria Veltri said she's glad the department is developing a tool kit. It will be particularly helpful, she said, for people who are seeking reimbursement after receiving a service.
But Veltri said that in acute cases, when a person needs approval for coverage right away or is at risk of having to leave treatment because coverage is being cut off, people will most likely continue to rely on her office for advocacy. "In the urgent and emergent arena, I think that what people most need is someone to take the burden off of them and help them advocate," she said, adding that it will be important to include consumers, advocates and insurance carriers in developing the tool kit.
And Veltri said she believes there are problems with insurers not following parity laws.
"The cases we are seeing are problems of denials with adequate information provided," she said.
The tool kit is a great idea, said Carol McDaid, co-chairwoman of the Washington D.C.-based Parity Implementation Coalition, a group of addiction and mental health consumer and provider organizations. But she said there are other issues with coverage that will still need to be addressed.
"While there are some issues with claims processing, I think it's bigger than that," she said.
Keith Stover, a lobbyist for the Connecticut Association of Health Plans, said the department's effort is likely to be valuable.
"Anything that makes the process smoother, and anything that makes it easier for patients to get access to mental health treatment is a good thing," he said.
While there have been calls to more fundamentally remake the coverage system for mental health services, Stover said the insurance department's approach is to ensure that the process for handling claims isn't a barrier to medically necessary treatment.
Lawlor said he hopes the tool kit is "just the first part of a process." Other things that need to be addressed, he said, are related to requirements that patients get pre-authorization for mental health or substance abuse treatment, authorization for continuing coverage, and whether patients have access to follow-up services after an acute episode in the same way a person who had a heart attack or stroke does.
The insurance department's announcement comes on the heels of changes to insurance law made as part of the gun-control legislation passed last week in response to the massacre at Sandy Hook Elementary School. Those include shortening the time insurers have to issue a decision on whether to cover mental health or substance abuse treatment in urgent situations, and requiring insurers to make it clear what criteria they use in determining whether services are medically necessary.
The changes drew praise from both Veltri and Stover. But Veltri said no one should think that the changes made so far can, on their own, "make the kind of substantive real change that needs to be made on a systemwide level." That's because more than half of privately insured state residents have plans that are not subject to state law. Self-insured health plans, which are common among large companies, are governed by federal law, not state statute.
"We have a lot of work to do," Veltri said.