BOSTON (State House News Service) – Groups representing insurance plans and behavioral health service providers scrapped Monday over a bill that would give clinicians a greater say in determining medical necessity for mental health services, a decision typically made by the insurer.
A bill (H 1070/S 1093) filed by Rep. Kay Khan and Sen. Jennifer Flanagan would add to the definition of “medically necessary services” the provision that, “Medically necessary services for mental health treatment shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.”
“As long as that definition is left in the hands of insurers, there is still a barrier to access to mental health services,” Susan Fendell, of the Mental Health Legal Advisors Committee, said. She added, “The interpretation of medical necessity criteria is too important to be left to insurance companies who do not have an intimate relationship with the patient, and we believe the patient and clinician are best able to determine medical necessity.”
The Joint Committee on Mental Health, Substance Use and Recovery, co-chaired by Flanagan, heard from Fendell and others who support the change, as well as opponents from the Massachusetts Association of Health Plans.
Dr. Joel Rubinstein, who served as associate medical director of Harvard Pilgrim Health Care for about 20 years and now advises MAHP, said that many people think of medical necessity in simplistic terms while it, in fact, has “a number of dimensions.”
“Medical necessity actually deals with levels of care. The question becomes will they be treated in a hospital? Will they be treated in a day program? Will they be treated in outpatient psychotherapy?” he said. “Medical necessity includes a whole lot of things, a number of things that a provider, certainly I as a provider, couldn’t have spoken to.”
Sarah Gordon Chiaramida, vice president of legal affairs for MAHP, said the association has concerns that the bills would limit an insurance “plan’s ability to do medical management, and also care management on behalf of Medicaid members.”
David Matteodo, executive director of the Massachusetts Association of Behavioral Health Systems, said the bill would put the decision of medical necessity in the hands of the person best positioned to make the decisions in consultation with the patient.
“This would, of course, put the decision of medical necessity in the hands of the treating clinician,” Matteodo said. “In my opinion, it is ludicrous that in the health insurance system we have really in the country, that people are making decisions on medical necessity without even seeing the patient, they can overrule the treating clinician.”
Matteodo said the Flanagan/Khan bill would extend to mental health services something that the Legislature did for substance abuse treatment services in a 2014 law that afforded insurance coverage for up to 14 consecutive days of medically necessary substance abuse treatment and abolished the ability of health plans to conduct medical necessity determinations.
“This provision is in that substance abuse bill. The Earth hasn’t fallen apart and the insurers fought it all the way through,” he said. “We think the system in substance abuse is much better … so we think this would be very important for mental health.”