Local Lawyer’s Work Prompts Major AG Pact

Ensures adherence to mental health parity laws

By Michael Turton

There was a strong local connection when New York State Attorney General Eric Schneiderman recently announced a settlement with Schenectady-based MVP Health Care. Cold Spring resident Michael Reisman, Assistant Attorney General with the OAG’s Health Care Bureau, conducted the investigation that uncovered widespread violations of New York’s mental health parity laws by MVP and led to the settlement. Reisman’s investigation found that since 2011, MVP through its behavioral health subcontractor, ValueOptions, issued 40 percent more denials of coverage in behavioral health cases than in medical cases.

The settlement requires MVP to reform its behavioral health claims review process, cover residential treatment and charge lower primary care co-payment for outpatient visits to most mental health and substance abuse treatment providers. It also requires MVP, which has more than 500,000 members in the Albany region, Central New York and the Hudson Valley, to submit previously denied mental health and substance abuse treatment claims for independent review, which could result in more than $6 million being returned to its members.

“Insurers must comply with the law to ensure that individuals with mental health conditions are treated no differently than those with physical ailments — and that they are getting what they pay for from insurers,” Schneiderman said in a press release issued on March 20.  New York’s mental health parity law, known as Timothy’s Law, was enacted in 2006, and requires that insurers provide mental health coverage at least equal to coverage provided for other health conditions.

The investigation revealed that before 2014, MVP did not cover residential treatment for behavioral health conditions, even though it is a standard, recommended, evidence-based form of treatment. MVP excluded this type of treatment while covering similar treatment for medical conditions. In one case, MVP denied coverage of residential treatment for a young woman with a severe case of anorexia nervosa, a potentially life-threatening condition. As a result, her family had to pay thousands of dollars out of pocket so that she could receive necessary treatment in a residential treatment facility.

As part of the settlement, MVP Health Care will cover residential treatment for behavioral health conditions, including eating and substance abuse disorders, and has designated $1.5 million for reimbursement of members’ past residential treatment claims that had previously not been covered. The OAG estimates that more than 3,000 MVP members may be eligible for reimbursement.

The investigation revealed that since 2009, when MVP outsourced administration of behavioral health benefits to ValueOptions, MVP has scrutinized behavioral health care claims more rigorously than it has medical and surgical claims, and that has resulted in thousands of its members not receiving coverage for care requested by their doctors and therapists. The disparity is especially pronounced in more intensive levels of care.

The plan denied 39 percent of its members’ claims for inpatient psychiatric treatment and 47 percent of its members’ claims for inpatient substance abuse treatment, rates that are more than double the plan’s denial rate for inpatient medical claims.

MVP Health Care has agreed to overhaul its claims review process by:

• Removing visit limits for almost all behavioral health services.

• Classifying claims correctly so that reviews are done expeditiously and members are afforded full appeal rights.

• Removing the requirement that members “fail” outpatient substance abuse treatment before receiving inpatient rehabilitation treatment.

• Basing the number of treatment days or visits approved on members’ needs rather than arbitrary limits.

• Ensuring that letters denying behavioral health claims are accurate and specific, so that members can exercise their appeal rights.

• Continuing coverage of treatment pending the completion of internal appeals, so that treatment is not interrupted.

• Appointing full-time behavioral health advocates to help members cut through red tape, and will provide information regarding claims review and treatment options.

MVP has also agreed to provide members with an independent review of claims that were denied as not medically necessary from 2011 on, which could result in more than $6 million in reimbursement to members. Claims for reimbursement for residential treatment services received since 2011 could also result in up to $1.5 million being refunded.

Reisman has been an Assistant Attorney General since 2012. Prior to that he was a commercial litigator with several prominent national law firms. He also had an active pro bono practice in such areas as patients’ rights and cases involving mental health issues.

Prior to receiving his law degree from the Benjamin N. Cardozo School of Law in New York City, Reisman was a psychologist and drama therapist in inpatient and outpatient settings in California, New York City, and the Czech Republic, where he was a Fulbright Scholar and lived for four years. He has also worked in professional theatre, writing and directing plays, in New York City, the Bay Area, and elsewhere. He has served on the Village of Cold Spring Special Board for the Comprehensive Plan/Local Waterfront Revitalization Plan since 2009.

Those with questions regarding the MVP settlement or other health care matters may call the Attorney General’s Health Care Bureau Helpline at 1-800-428-9071.