On February 26, 2019, the United States District Court released a ruling that United Behavioral Health (UBH/Optum), our country’s largest managed behavioral health care organization, maintained internal policies designed to save money by discriminating against individuals with mental health and substance abuse disorders.  Specifically, UBH was found to use flawed medical necessity criteria to broadly deny care for members.

Chief Magistrate Judge Joseph C. Spero ruled that UBH’s medical necessity guidelines did not comply with accepted standards of care and thus effectively resulted in the denial of outpatient, intensive outpatient, and residential treatment for hundreds of UBH members. Below is a direct excerpt from an American Psychiatric Association alert highlighting the guidelines disregarded by UBH:

  • Effective treatment requires treatment of the individual’s underlying condition and is not limited to alleviation of the individual’s current symptoms. 
  • Effective treatment requires treatment of co-occurring behavioral health disorders and/or medical conditions in a coordinated manner that considers the interactions of the disorders and conditions and their implications for determining the appropriate level of care. 
  • Patients should receive treatment for mental health and substance use disorders at the least intensive and restrictive level of care that is safe and effective – the fact that a lower level of care is less restrictive or intensive does not justify selecting that level if it is also expected to be less effective. Placement in a less restrictive environment is appropriate only if it is likely to be safe and just as effective as treatment at a higher level of care in addressing a patient’s overall condition, including underlying and co-occurring conditions. 
  • When there is ambiguity as to the appropriate level of care, the practitioner should err on the side of caution by placing the patient in a higher level of care. 
  • Effective treatment of mental health and substance use disorders includes services needed to maintain functioning or prevent deterioration. 
  • Appropriate duration of treatment for behavioral health disorders is based on the individual needs of the patient; there is no specific limit on the duration of such treatment. 
  • The unique needs of children and adolescents must be taken into account when making level of care decisions involving their treatment for mental health or substance use disorders. 
  • The determination of the appropriate level of care for patients with mental health and/or substance use disorders should be made on the basis of a multidimensional assessment that takes into account a wide variety of information about the patient.

As reported in the New York Times on March 5, 2019, Judge Spero noted that “there is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions.”

This case is of particular significance for patients and health care providers who have advocated for the use of more standard medical necessity guidelines developed by professional health organizations rather than guidelines custom-made by insurance companies. Further, this ruling highlights the court’s recognition of mental health and substance use disorders as potentially chronic conditions that necessitate treatment extending beyond crisis intervention for the most acute symptoms.

Undoubtedly, this ruling is a victory for our patients here at Columbus Park.  Our general outpatient and Intensive Outpatient Program services are indeed structured to address acute symptoms, but we go well beyond the initial crisis stage of treatment; we treat to outcome meaning, we treat to full recovery.  Maintaining insurance coverage for our patients throughout this process is essential.  We hope with this ruling, that we’ll see more transparency and consistency (with clear medical necessity guidelines) among UBH and other major insurance carriers.