United’s legal problems continue | Modern Healthcare

Six people petitioned the nation’s largest mental health insurance company with a proposed class action lawsuit on Thursday, alleging that United Behavioral Health continues to groundlessly and routinely deny insurance for mental health and drug addiction treatment.

Complaint filed with the U.S. District Court for the San Francisco Branch of the Northern District of California Repeats Claims and Extends Time Limits Wit et. al v United Behavioral Health, a landmark 2019 affair that resulted in United breaching its fiduciary obligations for approximately 50,000 members under the Federal Employee Retirement Act by deciding on mental health insurance on willfully inappropriate guidelines to increase profits.

A November 2020 court order required UBH to reform its claims processing process so that coverage decisions are based on generally accepted standards of care set by nonprofit medical groups. The judge also ordered UBH to re-process over 67,000 pending claims, a decision that UBH has appealed and is pending in court.

According to Caroline Reynolds, partner at Zuckerman Spaeder LLP, the Washington-based law firm that brought the initial cases to court, Wit has set a legal precedent on which to base common service standards. and is now representing plaintiffs in the proposed class action lawsuit.

“This was indeed the first ERISA class action lawsuit that looked at such guidelines on a broad, class-wide basis and found that the administrator was still bound by the terms of these plans and that they were required to use generally accepted standards. for leaving and not entitled to accept anything more restrictive, ”said Reynolds.

The Wit case concerned only UBH members whose insurance requests were denied by the insurer between May 2011 and June 1, 2017.

A separate class action lawsuit was filed against members whose claims were dismissed between June 2, 2017 and early February 2018, and this process is ongoing.

This new case aims to introduce “thousands” of patients who were denied mental health and drug treatment between February 2018 and 2019, arguing that UBH’s over-coverage decisions helped reduce the insurer’s bottom line while saving money for their self-financed clients, which increased the likelihood that employers will continue to rely on the insurer to manage their claims, Reynolds said.

“UBH’s policy is in accordance with state and federal laws and the insurer plans to actively defend itself in this case,” a spokesman wrote in an email.

“As part of our broader commitment to quality care, we continue to support our members with increased access to service providers and new ways to quickly get the effective behavioral support they need,” the spokesperson said.

The lawsuit states that UBH’s internal policies governing behavioral health coverage prioritized the financial interests of the insurer at the expense of patients’ health, allowing members to pay for treatment at high rates out of their own pockets.

In one case, UBH told Barbara Beach that it would only cover her daughter’s inpatient care for 12 days, despite doctors saying the girl’s suicide attempts, self-injurious behavior and medical diagnoses required a longer hospital stay. stay, according to the complaint. Instead, the insurer said it would cover the girl’s treatment under a partial hospitalization program located 1.5 hours from her place of residence. The complaint states that Beach was unable to transport his daughter to and from the nearest facility. She continued to treat her daughter in the hospital for as long as she could afford.

Because UBH required the facility to consolidate all of its services into a single daily bill, it was able to dismiss the claim altogether on the basis of its decision that inpatient treatment was not “medically necessary,” although some of the same services were would be paid for and provided as part of the partial hospitalization program. Reynolds said the insurer’s requirement for providers to pool their services into a single bill represents a new claim denial tactic, as it allows the insurer to deny all services provided, even if some of the components would likely be covered individually.

“The problem is that when these truly restrictive coverage criteria are applied, healthcare providers often give patients medical advice that they should take longer to heal,” Reynolds said. “So some people will stay at this level of treatment for longer, but UBH will not pay for any of that. Even though some of the services they received, UBH admitted that they are necessary. “

After all, Beach could not afford to keep her daughter in an inpatient program, the lawsuit says. The girl returned home early and eventually tried to commit suicide shortly after she was discharged and hospitalized due to an overdose.

“Patients are mostly faced with a choice: either pay for all treatment out of pocket, or have to receive treatment other than that recommended by their providers, or refuse treatment entirely,” Reynolds said.

Reynolds said that despite federal and state laws requiring insurers to cover behavioral care as well as physical care, patients often have serious problems getting carriers to pay for necessary treatment.

As an example, she pointed to UnitedHealthcare’s decision that, effective July 1, the insurer will no longer pay out-of-network claims when fully insured customers seek out-of-state non-emergency care. Under the new policy, patients will no longer have access to treatment in “lowered” health facilities far from where they live, including inpatient treatment programs and inpatient rehabilitation groups.

Reynolds said that if this policy is extended to self-insured clients, she is not confident that the policy will meet the standards of the Mental Health and Addiction Treatment Act, which requires insurers to evaluate their policies to ensure they do not deny a disproportionate amount of number of mental health services.

“I often describe the challenges employees face in trying to get the health insurance they need according to their plans like playing the mole,” Reynolds said. “Insurers are finding more sophisticated forms of discrimination, such as these non-quantitative restrictions. We really see this a lot, and it’s a constant struggle to stay on top of all the different constraints that are being imposed. ”