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Mental Illness

Like gastric bypass cases, IROs frequently arrive at different conclusions than the HMOs concerning mental illness. Out of the 263 reviews studied, 46 involved treatment for mental illness. Eleven of the 46 cases all related to eating disorders (see separate discussion, page 13). Of these 46, 32 (70 percent) were either fully or partially overturned. For the most part, the dispute centered on the duration of an inpatient or residential treatment facility stay. Without access to the underlying documentation, Consumers Union could not fully evaluate the HMOs' denials, but there are some basic standards that come into play regularly during the IROs' reviews of these cases.

IROs upheld HMO denials that involved patients undergoing a change in medication that could have been handled on an outpatient basis. In addition, if the patient showed obvious improvement and demonstrated a desire to get better, the IRO was likely to uphold the HMO's denial of continued inpatient care. Lastly, a few decisions were upheld simply because the patients' medical records were inadequate. For example, in one case, a reviewer held that while it did appear that the patient had "significant medical and psychiatric problems, including dementia with memory impairment, a history of depression, substance abuse, and violent threats and behavior," there was "grossly inadequate documentation" supporting the need for inpatient care.(17)

Most HMO denials were at least partially overturned, but the standards are a little cloudier. If the patients' records indicated they were still having suicidal thoughts, had undergone many medicine changes within a short time period, were lethargic, confused, violent, or showed no interest in committing to an unsupervised situation, the IROs overturned all or part of the HMOs' denials.

BCBS denied residential treatment for an adolescent female with an IQ of 64 who had assaulted her mother. The reviewer concluded that the patient's history of violence toward her family and self-destructive acts clearly indicated that she was entirely out of control. In this instance, as in many others, the reviewer could find no responsible explanation for the HMO's denial of residential care.(18)

During a woman's hospitalization for severe depression, United Healthcare refused to grant her a therapeutic pass. The independent reviewer found it unfortunate that "the insurance that covered her hospitalization conveyed to me that, 'If she were healthy enough to go on a pass, then she was healthy enough to be discharged.'" The pass had enabled the patient to spend time with her mother, the reviewer held, an essential step in her recovery.(19)
Sometimes the HMO wanted to move the patient to a lower level of care (residential treatment, partial hospitalization). TMF issued a decision concerning a young boy who had previously tried a long term program. He complained of voices telling him to harm others and had a plan to murder his mother and stepfather as they slept and then kill himself. TMF found that because the boy was so young, the HMO should have allowed a longer hospitalization. "It is a well known fact among child psychiatrists that children have more difficulty dealing with transitions than adults and need more preparation time for discharge," the reviewer concluded.(20)

In another example, Private Healthcare Systems agreed to cover only four days of inpatient treatment for a patient admitted by police in four point restraints with bipolar, seizure and cognitive disorders. At the time of proposed discharge, the patient was still suffering from seizures, was agitated and required restraints. An Envoy reviewer found that this patient could not be safely cared for at any other level than "acute inpatient care," and should not be transferred. Still in the hospital at the time of the review three weeks later, the reviewer felt that she should remain an inpatient until her physician was ready to move her.(21)

Patients covered by PacifiCare of Texas appealed five decisions related to mental illness. The IROs overturned three of the five. The reviewer upheld one of these because the psychiatrist did not provide enough information.(22) All of the overturned cases involved records that the reviewers believed demonstrated that the patients were still in the midst of treatment and had not shown much improvement. In one case, a patient was admitted on suicide watch and the HMO wanted her transferred to residential treatment two days later. The reviewer believed that her two unsuccessful prior admissions indicated that it was not safe to discharge her.(23)

Some advocates for people with mental illness contend that managed care companies have gone too far in their efforts to wring unnecessary inpatient care out of the mental health system. Studies based on the national household survey, Health Care for Communities, find that respondents seeking treatment for mental health and substance abuse problems report delays in treatment or less treatment, but are less likely to report no treatment under managed care plans.(24) Although we could not review and categorize a large number of cases, our research identified several individual examples of overly aggressive discharge from inpatient mental healthcare that were corrected through access to the independent review process.

Substance Abuse

More than a fifth of all the cases related to substance abuse treatment (54 cases). IROs overturned more HMO denials related to substance abuse than the average "overturn rate" (60 percent or 32 cases). Like mental illness cases, these appeals dealt mostly with the patient's length of stay in an inpatient care or residential treatment facility, or their removal from inpatient care to a lower level of care (outpatient, residential, partial hospitalization). Reviewers identified a number of criteria when they examined cases-level of documentation, level of home support, level of patient commitment to drug treatment, years of drug addiction, and level of withdrawal-and frequently overturned HMO decisions for the most severe cases. Of the 22 HMO decisions upheld by the IROs, some supported the HMOs' determinations primarily because the patients' families appeared supportive and non-chaotic.(25) They tended to uphold the HMO if the patient showed little or no withdrawal or had no complications.(26) Finally, reviewers tended to uphold an HMO determination if the patient was making good progress with good motivation (and therefore could successfully move to outpatient care) or if the patient was making little or no progress.(27) On the other hand, reviewers approved additional treatment time (or a higher level of care) for patients with other complicating mental illness, those with a severe detoxification, and those with serious family conflicts at home.(28) In some cases, we were surprised at how little inpatient treatment time a managed care company would provide for severe addictions. An alcoholic of 20 years with a history of depression entered the hospital for detoxification. After two days, he was discharged to finish his detoxification as an outpatient. The HMO denied coverage for the two days of inpatient care. The reviewer determined that his severe withdrawal symptoms warranted his two-day stay.(29) Another patient with combined cocaine and alcohol dependence was granted only four days for inpatient detoxification, then moved. The reviewer noted his additional diagnoses of hypothyroidism and depression, and added another 5 days.(30)

Reviewers overturned several denials because the patients had already been unsuccessful in outpatient treatment.(31) For example, one patient addicted to multiple substances, complicated by chronic pain, entered inpatient detoxification. The HMO denied the care, and the reviewer overturned the decision because the patient's prior attempts to withdraw from opiates on an outpatient basis had failed. Inpatient detoxification was medically necessary.(32)

At least 25 of the 54 substance abuse cases (46 percent) involved teenage abusers. About half these HMO decisions were overturned (13 of 25 or 58 percent).(34) In most cases, the substance abuse was coupled with juvenile crime, running away, family conflict and other problems. In response, families most frequently requested residential treatment-programs designed to give the teens 24-hour supervision apart from other substance-abusing friends or family conflicts. Each of these cases presents a snapshot of a very troubled family seeking some kind of help that they believe is covered under their insurance-and not necessarily getting it. (See Substance Abuse and Teenagers, p. 10.)

These cases also illustrate the importance of a family advocate when faced with insurance denials for mental health and substancse abuse care. Parents, or some other advocate within the system, took the time to make sure their child got the care covered under the insurance plan (first asking for internal review, then for independent review). Individuals without strong family or other support may find this process difficult to navigate on their own.

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Footnotes:

17 Independent Review Inc., IRO Decision Letter, BCBS, 9/4/2001. The statute gives the IRO access to any medical records of the enrollee that are relevant to the review, any documents used by the plan in making its determination, the notice to the consumer explaining the determination, any documentation submitted in support of the appeal, a list of each physician or provider who may have medical records relevant to the appeal. In some cases it appeared that the documentation problem originated with the providers, whose notes or other information were insufficient to support the requested treatement.

18 Independent Review Inc., IRO Decision Letter, BCBS, 8/15/2001.

19 Independent Review Inc., IRO Decision Letter, United Healthcare of Texas, 6/20/2001.

20 Texas Medical Foundation, IRO Decision Letter, HMO Blue, 4/11/2001.

21 Envoy, IRO Decision Letter, Private Healthcare Systems, 6/6/2001.

22 Texas Medical Foundation, IRO Decision Letter, Pacificare, 4/23/2001.

23 Envoy, IRO Decision Letter, Pacificare, 7/23/2001.

24 RAND Research Highlights, "Are People With Mental Illness Getting the Help They Need," download date, 3/28/2002.

25 Texas Medical Foundation, IRO Decision Letter, Magellan Behavioral, 8/8/2001. Envoy, IRO Decision Letter, Corphealth, 6/8/2001.

26 Independent Review Inc., IRO Decision Letter, Prudential Healthcare, 9/11/2001. Texas Medical Foundation, IRO Decision Letter, Aetna, 5/17/2001. Envoy, IRO Decision Letter, Magellan Behavioral, 8/28/2001.

27 Texas Medical Foundation, IRO Decision Letter, Prudential Healthcare, 4/3/2001. Texas Medical Foundation, IRO Decision Letter, Unicare, 5/1/2001. Envoy, IRO Decision Letters, Magellan Behavioral, 8/15/2001, 8/28/2001. Independent Review Inc., IRO Decision Letter, Clarendon, 5/16/2001. Independent Review Inc., IRO Decision Letter, National Health Service, 5/29/2001.

28 IR, IRO Decision Letter, Cypress Creek Hospital, 5/22/2001. Envoy, IRO Decision Letter, Cigna, 5/3/2001. Envoy, IRO Decision Letter, Humana, 4/11/2001. Independent Review, IRO Decision Letter, Corphealth Inc., 3/27/2001. Envoy, IRO Decision Letter, Magellan, 4/23/2001. Independent Review, IRO Decision Letter, Principal Life IC, 5/9/2001. Envoy, IRO Decision Letter, Cigna, 9/5/2001. Independent Review, IRO Decision Letter, BCBS, 8/3/2001. Independent Review, IRO Decision Letter, Cigna, 6/13/2001. Independent Review, IRO Decision Letter, Humana, 9/12/2001. Texas Medical Foundation, IRO Decision Letter, HMO Blue, 7/2/2001. Envoy, IRO Decision Letter, Humana, 8/6/2001. Envoy, IRO Decision Letter, Magellan, 4/23/2001. Texas Medical Foundation, IRO Decision Letter, John Aldan IC, 5/17/2001. Envoy, IRO Decision Letter, US Healthcare, 4/16/2001.

29 Independent Review, IRO Decision Letter, BCBS, 8/3/2001.

30 Independent Review, IRO Decision Letter, Cypress Creek, 5/22/2001.

31 Envoy, IRO Decision Letter, HMO Blue, 5/17/2001. Envoy, IRO Decision Letter, Magellan Behavioral, 8/14/2001. Envoy, IRO Decision Letter, Humana, 8/6/2001.

32 Envoy, IRO Decision Letter, Cigna, 9/13/2001.

33 Envoy, IRO Decision Letter, US Healthcare, 4/16/2001. Envoy, IRO Decision Letter, Cigna, 5/3/2001. Independent Review, IRO Decision Letter, BCBS, 7/2/2001. Envoy, IRO Decision Letter, Magellan Behavioral, 8/14/2001. Envoy, IRO Decision Letter, Magellan Behavioral, 9/5/2001. Texas Medical Foundation, IRO Decision Letter, Humana, 9/5/2001. Texas Medical Foundation, IRO Decision Letter, BCBS, 7/24/2001. Texas Medical Foundation, IRO Decision Letter, John Alden IC, 5/17/2001. Envoy, IRO Decision Letter, Humana, 8/6/2001. Independent Review, IRO Decision Letter, John Alden IC, 6/1/2001. Independent Review, IRO Decision Letter, BCBS, 7/6/2001. Independent Review, IRO Decision Letter, Aetna, 7/27/2001. Independent Review, IRO Decision Letter, HMO Blue, 8/31/2001.

34 Envoy, IRO Decision Letter, Prudential, 5/18/2001. Texas Medical Foundation, IRO Decision Letter, Prudential, 5/15/2001. Envoy, IRO Decision Letter, Healthsmart Preferred Care, 7/27/2001. Texas Medical Foundation, IRO Decision Letter, Insurance Management Svs, 9/14/2001. Texas Medical Foundation, IRO Decision Letter, Prudential, 3/22/2001. Texas Medical Foundation, IRO Decision Letter, Fortis, 3/3/2001.