An Ohio psychologist who served as an Army psychologist in war zones in Iraq and Afghanistan contends United Healthcare (UHC) is denying needed treatment for a PTSD client formerly seen on a weekly basis by limiting reimbursement to cover no more than one session every two weeks.
Kathy Platoni, Psy.D., said she was notified in February that “it was determined that one of my patients was receiving entirely too much treatment” and she would be subjected to a “peer to peer” review of her treatment plan.
“How UHC came to this conclusion is beyond comprehension, unless a UHC representative was sitting in my office during this particular patient’s treatment sessions for the last 18 months,” Platoni said. Platoni, a retired Army colonel now in private practice in Dayton, Ohio, said in addition to her war zone service she has co-authored two books on war trauma and has been recognized nationally as an authority on the treatment of PTSD.
She said the review was conducted in a 25-minute phone call with a master level clinician representing UHC. “I made it extremely clear that this particular patient demonstrated extremely severe signs and symptoms of PTSD and that a continuation of weekly psychotherapy was an absolute necessity,” Platoni said.
She said the UHC clinician told her another clinician would review her comments and UHC would get back to her. Platoni said the next day she was informed the decision would be reviewed at a higher level and she could either submit to a telephone interview by a doctoral level clinician or the second clinician could conduct “a records review.”
Platoni chose the records review and a few days later was informed treatment would only be authorized for sessions every other week. She said she was subsequently denied reimbursement for two sessions that pre-dated UHC’s decision to restrict treatment.
“It is extremely likely that this patient will rapidly regress and decompensate,” Platoni said. She said she considers it highly unethical for UHC to place cost containment above the needs of a patient. She said she filed complaints with the Ohio Department of Insurance and the Ohio Board of Psychology but was informed they have no authority in the matter.
Problems in receiving reimbursement for services from insurance companies are hardly new to psychologists and other mental health professionals, and complaints about payment limits are not new to UHC.
The company is the defendant in two pending federal lawsuits in California that allege widespread denial of mental health claims to save money, as reported in the January/February edition of The National Psychologist. Observers say if those suits are successful, cost containment practices of UHC and other insurers could be found in violation of the national parity law and they would be forced to provide greater coverage.
Another psychologist, Jerry M. Lazaroff, Ph.D., of Media, Pa., told The National Psychologist that Humana Insurance was recently awarded the contract under TRICARE coverage for military personnel in the eastern half of the United States. TRICARE covers a variety of mental health and substance abuse services.
Lazaroff said Humana Military immediately imposed severe cost-containment reductions in reimbursement compared to Health Net Federal Services that formerly administered the services. He said under Health Net a psychologist was eligible for reimbursement of 90 percent of the maximum allowable charge of $66.26 under Medicare guidelines for a session of 38 to 52 minutes.
He said Health Net paid 70 percent of the cost and a psychologist could collect another 20 percent in co-pay from the patient. But, he said, Humana has notified him that it will be deducting the patient’s co-pay from the provider’s payment, thereby reimbursing only at a 50 percent rate.
Lazaroff said he requested clarification and received an email from Humana that said, “The total amount you would receive would be $46.48. Humana would pay $33.13 and the beneficiary would pay $13.13.” The net effect, Lazaroff said, is that reimbursement will drop from 90 percent of the allowable maximum to 70 percent.
He said as a result he does not intend to join Humana Military, adding “…if other psychologists feel similarly, then TRICARE members may be under served.”