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Docs protest Blues’ new rule

By Carol Gentry
6/17/2009 © Health News Florida

Blue Cross and Blue Shield of Florida has ordered mental-health providers who treat the company's patients to begin getting permission before doing so if they want to get paid. While this has long been the policy for HMO patients, it's a new requirement for millions of Floridians in BCBS-FL's other plans -- including state employees.

Those affected are customers enrolled in traditional insurance products or preferred provider organizations (PPO) plans, including Blue Options, Network Blue and the state employees' PPO plan.

The requirement that mental-health providers get "prior authorization" before seeing BCBF patients except in emergencies was announced in a May 29 letter from Barry B. Schwartz, BCBS vice president for network management. The contract must be signed by June 24 if doctors want to be paid for visits after Oct. 3, the letter and accompanying fact-sheet said.

What galls doctors most, they say, is the reason Schwartz gave for adding this new layer of red tape: the  federal Mental Health Parity Act, which requires insurers to provide equal coverage for treatment of physical and mental ailments. It goes into effect Jan. 1, which occurs after the beginning of the coverage year for most plans.

In a letter to Schwartz, Gainesville psychiatrist Phillip W. Cushman protested: "You are deliberately slowing down the time it takes to get a patient in with a psychiatrist and you are creating a barrier that will place limits on psychiatric patient care that do not exist with any other medical specialty. Many psychiatrists do not have staff available to go through the onerous and time-consuming process of obtaining prior authorization for patient visits. In addition, the treatment plan that you will require often takes an entire patient visit for a psychiatrist to prepare and this is time that could be better put to directly helping the patient rather than on bureaucratic paper work."

Winter Park psychiatrist Louise Buhrmann agrees. “The whole point of parity was to put mental health on par with any other health need,” she said. “This new plan puts a road block in the way of patients getting help for psychiatric problems.”
Schwartz said such concerns are overblown, that the restrictions being extended to the company’s insured products already apply in its HMO and the plan for federal employees. Emergencies will be covered without prior approval, he said, and prior authorizations can be granted in bunches, if warranted, to reduce the time required in filling out authorization requests. They have until the ninth visit to submit a treatment plan, he said.
"This will have no effect on reducing behavioral health care," Schwartz told Health News Florida. “It’s really not a big deal, frankly.”
Schwartz said BCBS-FL had to make the change because the new parity law could trigger a flood of treatments for mental-health and substance-abuse complaints. “All of a sudden, people have a lot more benefits, there’s a lot more money invested in it," Schwartz said. "We have a responsibility to manage that money and those benefits responsibly.”
When the company could limit coverage of mental-health treatment to a defined number of visits, Schwartz said, “we weren’t terribly concerned. Once the door is thrown open and the benefits are essentially unlimited, it becomes a much bigger issue regarding cost.”
Buhrmann says she will not sign the contract amendment. "I'm sure they've run it by their lawyers and it's legal. But it's not right."

 Cushman won't sign either, although it means the end of a 37-year relationship with Blue Cross. In a letter to his patients, he wrote, "The Mental Health Parity Act was fought for by psychiatrists and is meant to ensure that financial requirements and treatment limitations applicable to mental health/substance use disorder benefits are no more restrictive than those requirements and limitations placed on medical/surgical benefits. 

"BlueCross/BlueShield’s attempt to tie their revision of contracts to the Act flies in the face of the Act and everything Congress was trying to accomplish."

Schwartz countered that the company already requires prior authorization for radiologists who do advanced imaging techniques, such as CAT scans and MRI's, and for injectable drugs. "We require preauthorization any time we think there's a potential problem in managing costs," Schwartz said.

Cushman's letter says the time-consuming requirements will likely result in fewer psychiatrists accepting BCBS patients. "With most psychiatrists no longer providers for Blue Cross you will be turned over to those with less experience and that will likely save Blue Cross money," he wrote to his patients.

Buhrmann said she has about 50 active BCBS patients who are on medications that require a physician's knowledge to monitor. "I really don't want to give them up," she said.
Primary-care physicians will inherit the task of monitoring the drugs for the complicated patients she sees -- including those who have reactions to common medications and many patients with bipolar disorder.

"It's not good for the (psychiatrists), for the patients, or for the family doctors," she said.

--Contact Carol Gentry at 727-410-3266 or by e-mail.