Market conduct review leads to new fund to supplement behavioral health care system in RI

Blue Cross Blue Shield Rhode Island stopped requiring prior approval for in-network mental health or substance use disorder services on Aug. 1, a move the state’s largest health insurer said was part of a larger focus on improving access to care.

Out-of-network services will still be subject to what’s known as utilization review for behavioral health services.

But left out of the BCBSRI news release when this policy change was initially announced last May was the fact that the discontinuation of the process known as utilization review came about during discussions with state regulators.

That’s after examiners from the Rhode Island Office of the Health Insurance Commissioner (OHIC) documented multiple flaws in BCBSRI’s utilization review criteria for coverage over the course of a detailed review of the insurer’s records that began in January 2015.

OHIC is conducting market conduct examinations of all four of Rhode Island’s major insurers to measure compliance with the Affordable Care Act. The law requires that insurers offer mental health and substance use disorder coverage comparable to that for general medical and surgical care.

The BCBSRI review was the first to be released on Sept. 17. Clinicians from the Law and Psychiatry Service at Massachusetts General Hospital provided expertise for the review of a random sample of 444 cases, most from 2014.

OHIC’s report found that BCBSRI’s used “clinically inappropriate” review criteria and that documentation of the criteria was “inadequate.”

The examiners concluded that different utilization review staff “reached very different conclusions based on similar facts and clinical circumstances.” Additionally, the insurer “conducted frequent, short-term reviews of coverage…without an objective or clinical basis” and that utilization review procedures were “unreasonable and inequitable” and “did not properly consider patients’ welfare and safety.”

The examiners also found BCBSRI’s practices for prior authorization of prescription drugs used to treat behavioral health conditions “led to impeded or delayed care or potential impeded or delayed care.”

Instead of a penalty, however, regulators reached a settlement to establish a $5 million fund — with BCBSRI contributing $1 million per year over the next five years — to improve access to care and treatment for individuals with mental health and substance use disorder conditions.

The fund will be administered by the Rhode Island Foundation. The process of soliciting proposals for prevention and early intervention programs was expected to start by the end of October, foundation spokesman Chris Barnett said.

“Blue Cross was extremely cooperative,” OHIC Commissioner Marie Ganim said in an interview. “One of the reasons why the settlement was agreed to was that they have agreed to discontinue utilization review for in-network behavioral health providers.”

Ganim also noted that BCBSRI had started to correct deficiencies to improve the mental health system even before the report was released.

Among other policy changes BCBSRI had announced, effective Jan. 1, 2019, all its insured plans will provide coverage for all mental health and substance use disorder office visits, including medication-assisted treatment (MAT), at a copayment consistent with primary care office visits instead of specialist visit copays, which are often higher.

Last spring, BCBSRI partnered with the Addiction Services Center at Roger Williams Medical Center to provide MAT to Rhode Islanders struggling with opioid use disorder.

It announced its support of Bradley Hospital’s Mindful Teen Program, a six-month evidence-based Dialectical Behavior Therapy treatment for adolescents (DBT-A) ages 13 to 18 years old to help them avoid crises that might lead to inpatient hospitalization.

Rhode Island Psychological Association Director of Professional Affairs Peter M. Oppenheimer, Ph.D., welcomed the market conduct studies and looked forward to seeing the outcome of the other three reviews still pending.

“It has long been my experience with utilization review agents that the rules were often arbitrary, and the agent’s application of the criteria arbitrary or inconsistent,” Oppenheimer said, adding he was pleased that BCBSRI was cooperating with regulators.

“I don’t think that complaints about BCBSRI were more frequent or egregious than the other companies operating in Rhode Island,” Oppenheimer said.

The reviews of UnitedHealthcare, Neighborhood Health Plan of Rhode Island and Tufts Health Plan will be forthcoming, Ganim said.

Janine Weisman is a journalist based in Newport, Rhode Island, who frequently writes on mental health. Find her on Twitter at @j9weisman.