By Sara Jasper, JD
Staff Attorney
The Therapist
 May/June 2013

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CAMFT receives frequent calls from members who are experiencing, or who have experienced, difficulty obtaining information and authorizations for outpatient treatment of patients from health care plans. The members' concerns are legitimate and understandable. CAMFT works in a number of ways to help address these types of issues.

CAMFT co-sponsors and/or supports legislation that requires health care plans to work with providers to ensure the best outcomes for managed care clients. For example, CAMFT recently submitted a letter of support for SB 22, a bill that will assist with enforcement of state and federal health parity laws.

CAMFT also belongs to the Consumer-Provider-Plan Agency Mental Health Work Group ("CPPA"), run by the Department of Managed Health Care ("DMHC"). This work group gives provider associations and health care plans an opportunity to regularly come together to work through the ongoing problems facing providers and plans that have continually caused strife for members and consumers.

To provide health plans in the CPPA work group with data about the difficulties CAMFT members experience when seeking authorizations for treatment of managed care patients, CAMFT occasionally conducts surveys regarding provider satisfaction and experiences with health care plans and insurers.

The 8-question survey discussed below was sent to a sample of 9,116 Clinical members. Four hundred and twenty-four of those members participated in the survey.

Question 1: When asked if they experience any problems or concerns when attempting to determine a patient's benefits eligibility related to outpatient mental health services, 68.2 percent of the survey respondents indicated that they experienced problems. Thirty-two percent of respondents indicated they did not experience problems.

Question 2: When asked about the specific problems they have encountered, 194 respondents indicated the following types of problems:

• Difficulty determining who provides coverage for mental health benefits due to lack of information on the insurance card
• Long wait times when calling the health care plans to obtain information about coverage
• Difficulty navigating through and understanding the automated systems
• Inability to speak to a live person about their clients' coverage
• Health care plan representatives' inability to answer their specific questions

"Misinformation regarding authorizations, deductibles, co-payments, pay rates, proper addresses to bill, fax numbers to use

• Lack of information available on the insurance websites
• Lack of access to insurance websites
• Difficulty determining whether an authorization is needed
• Difficulty understanding out-of-state plans
• Language barriers of the health care plan representatives

Question 3: When asked what they have done to attempt to resolve the issues, 193 respondents indicated having taken the following actions:

• Called the insurance company to attempt to resolve their issues
• Resubmitted claims
• Wrote the insurance company
• Complained to the insurance company
• Appealed the claim denials
• Asked clients to call the insurance companies
• Submitted complaints to the Department of Managed Care
• Did nothing

Question 4: When asked what the results of their efforts were, 177 respondents indicated the following:

• Thirty-nine of the survey respondents indicated they were ultimately successful in resolving their issues with the insurance companies.
• Fifty-one of the survey respondents indicated that they were ultimately unsuccessful in resolving their issues with the insurance companies.
• Fifty-six of the survey respondents indicated that their problem solving efforts have had mixed results, and that some have been successful and some have not.
• Nine of the survey respondents indicated that their issues with the insurance companies remain unresolved.

Twenty-two of the survey respondents indicated that they received no response from the insurance companies.

Question 5: When asked if they experience any difficulty when attempting to obtain authorizations for continued treatment:

• 44 percent of the 333 respondents indicated they do.
• Fifty-six percent of respondents indicated they do not experience difficulty.

Question 6: When asked what specific difficulty they have when attempting to obtain authorizations for continued treatment, 120 respondents indicated the following:

• Eight of the survey respondents indicated they received no response from insurance companies.
• Thirty-eight of the survey respondents indicated they received denials for coverage.
• Ten of the survey respondents indicated that the insurance companies they work with discourage them from continuing care with their patients.
• Eighteen of the survey respondents indicated that review processes are extensive and invasive.
• Twenty-nine of the survey respondents indicated they often spend a lot of time on the phone answering questions. Ten of the survey respondents indicated they often spend a lot of time filling out extensive paperwork.
• Seven of the survey respondents indicated they receive authorizations for a limited number of sessions, regardless of the particular facts and/or circumstances of the case (e.g. chronic illness, patient in crisis, etc.).

Question 7: When asked what they have done to attempt to resolve the issues regarding requests for continued treatment, 112 respondents indicated having taken the following actions:

• Called the insurance companies to attempt to resolve the issue
• Wrote letters
• Appealed the decisions
• Complained to the Department of Managed Care
• Did nothing

Question 8: When asked what the results of their efforts were, 100 respondents indicated the following:

• Fifty of the survey respondents indicated that services for their client were ultimately approved.
• Twenty-seven of the survey respondents indicated that they continued to receive claim denials.
• Ten of the survey respondents never received responses. Issues were never resolved.
• Thirteen of the survey respondents were so frustrated that they started taking cash-only

What Providers Can Do to Help Change the System
To improve your own experience with health care plans, CAMFT first suggests reading and understanding the contracts you sign. When you contact a health care plan for information, be sure to document the date, time, and name of the representative who provided you with information or answers. Make sure to make copies of letters, emails, and faxes sent to and received from the plans. You should also become knowledgeable about the laws surrounding managed health care. For more information about managed health care laws and how to structure an appeal to a managed health care plan, we encourage you to read the article "Managed Health Care: California Law and Your Rights" by Catherine Atkins. The article can be found on the CAMFT website at www.camft.org. For those experiencing similar difficulties with outpatient care, simply fill-out an online AMA Health Plan Complaint Form at www.ama-assn.org/go/clickandcomplain.

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Sara Jasper, JD, is a staff attorney for CAMFT. Sara is available to answer member calls regarding legal, ethical, and licensure issues.