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Federal investigation reveals parity violations

February 17, 2016

The federal government is enforcing parity and investigating violations, according to a report by The U.S. Department of Labor. “Improving Coverage for Mental Health and Substance Use Disorder Patients” presents information on mental health and substance abuse parity violations investigated among insurance carriers from October 2010 through the end of 2015.

“It’s one thing to hear the complaints, frustrations and difficulties of getting paid by carriers anecdotally and another to see where the Department of Labor is specifically finding problems,” says Marvin Ventrell, executive director of the National Association of Addiction Treatment Providers (NAATP).

While there have been successes with the Mental Health Parity and Addiction Equity Act and progress has been made in terms of enforcing and implementing the law, the report found both quantitative (payment-oriented) and non-quantitative (access-oriented) violations. Among the 1,515 investigations carried out, 171 violations were found—58 percent of which were non-quantitative.

Government action

Bottom line, Ventrell says, the government is acting and the industry should be pleased. But while parity has given the industry a tool to work with, parity by no means is where it needs to be.

“There are substantial violations that need to be corrected in order for millions of people to get the care that they need,” he says. “We’re talking 22 million people in 2014 ages 12 and over reporting that they did not get addiction care when they needed it—that’s a lot.”

Ventrell adds that the industry must treat this as a broad systemic concern. Insurance commissioners and attorneys general on the state level can be active or inactive, he says, but being more active will improve statewide healthcare and prevent deaths.   

“There’s a regulatory administrative process that states can be very helpful with, but individuals and agencies also need to do their part, which is to report,” he says.

Ventrell says that consumers may have coverage that they don’t know about or they might not be aware they can appeal denied coverage. It’s up to the Department of Labor to educate the public. 

“These [violations] are still really underreported,” says Scott Munson, CEO of Sundown M Ranch. “There are many more going on, but it’s difficult to get people to identify and go through what it takes to actually file a complaint and have it investigated and have a finding.”

Similarly, individuals and treatment providers must work to educate carriers, demand coverage, and make sure a denial has a valid reason.

“Payers are getting more sophisticated in their ways to deny,” Munson says. “I don’t think we’ve seen any real significant reduction in the level of scrutiny or the denial of care—yet.”

It’s not out of the question to convince a provider to pay when the proper information is presented, Ventrell adds. But it’s necessary to document those calls and interactions so if there is a violation, it can be reported with data and taken care of by the state.

“The system is very difficult to work under, and this is not the standard of operation in other disease fields,” says Ventrell. “Let’s all as agencies—healthcare providers, insurers, patients and treatment centers—look at this and figure out what the various concurrent approaches to solving the problem are.”

Munson adds that the violations in the report are just the tip of the iceberg.

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