Assembly Seeks Help for Members Appealing Insurance Denials

At its meeting in May at APA’s 2018 Annual Meeting, the APA Assembly took action on a number of issues important to the Association, the field of psychiatry, and its patients. One of the major issues it tackled could result in members’ achieving more success when appealing claim denials.

Specifically, an action paper approved by the Assembly requests that APA improve its webpage titled “Appealing Treatment Denials” by adding a user-friendly toolkit describing the steps to follow to maximize the likelihood of an appeal’s success. The motion, and others approved by the Assembly, are not APA policy until they are approved by the Board of Trustees, which meets this month at APA headquarters in Washington, D.C.

“The APA website has some advice for clinicians about appeals, but it is not currently written or structured in a user-friendly format,” said resolution author Eric Plakun, M.D., chair of the Assembly Committee of Representatives of Subspecialties and Sections and a member of the Assembly Executive Committee. Plakun said many patients and the psychiatrists who treat them have had the experience of insurance coverage denials for treatment of mental illness, including substance use treatment, that they believe is medically necessary.

“Fewer than 5 percent of appeals are successful when reviewed by the insurance company issuing the initial denial or by their contracted appeal review agency,” according to the action paper. “When the appeal review agency is truly independent, the success rate for appeals jumps to nearly 60 percent. Appealing such denials can be a complicated, frustrating, and confusing process that is often difficult to navigate.”

The action paper noted that appeals are most likely to lead to a reversal of a denial when the following factors are included: use of the patient’s voice as an active agent in the appeal process; anchoring appeals to third-party resources representing generally accepted standards, such as APA practice guidelines, the Level of Care Utilization System (LOCUS) developed by the American Association of Community Psychiatrists, or relevant published research; and invocation of the federal mental health parity law.

The Assembly also approved a variety of other action papers and position statements related to clinical practice, professional scope of practice, advocacy, member education, and internal APA policies. One of those resolutions addresses medication-assisted treatment (MAT) of physicians in state physician health programs, which help advocate for physicians in recovery to keep their licenses.

The Assembly action paper, written by Kenneth Certa, M.D., of Pennsylvania, noted that some physician health programs forbid the use of agents such as methadone and buprenorphine, though it is not clear that use of such drugs by physicians poses a risk to the public.

“Physicians under supervision of the health programs may be required to forgo some of the most effective treatments for substance use disorders,” the action paper states.

The action paper seeks to have APA review available evidence on the use of MAT by physicians in recovery and develop a position statement on MAT use in physician health programs. The resolution further asks that APA work with the AMA and other groups to ensure that physicians seeking treatment of substance use disorders have access to MAT.

The Assembly approved several action papers related to scope of practice. One of these calls on APA to support research to determine the efficacy and safety of unsupervised mental health practice by psychiatric nurse practitioners and physician assistants. Further, the resolution asks APA to develop a position statement in support of appropriate supervision of these practitioners.

Additionally, the resolution asks APA to advocate that health care professionals wear something that indicates their licensure large enough for all patients to see.

The following items, among others, were also approved by the Assembly:

• Teaching improved treatment of borderline personality disorder (BPD): The Assembly approved an action paper that calls on APA’s Division of Education to create a Supplemental Education and Training learning module on common-factor treatment approaches for BPD. The paper noted that BPD is present in approximately 10 percent of psychiatric outpatients and 20 percent of psychiatric inpatients. In non-psychiatric settings, the disorder is present in 6 percent of primary care patients. The mainstay of treatment is psychotherapy. There are several “common-factor” approaches that do not require intensive training to successfully treat patients living with this disorder. Psychiatry residencies can use the limited time available to teach a common-factor approach and address issues related to misdiagnosis, underdiagnosis, lethality, and adverse impact on the course of other psychiatric conditions.

• Improving access to American Board of Psychiatry and Neurology (ABPN) examinations: Maintenance of Certification (MOC) through the ABPN includes a requirement to pass an examination every 10 years. The recertification examination is offered at specific testing sites throughout the United States during two five-day periods annually. Psychiatrists have professional and personal commitments that may compete with these extremely limited testing dates. APA is working with the ABPN to improve MOC, and the Assembly action paper calls on APA to advocate for a minimum of four five-day examination periods through the year.

• Increasing access to atypical long-acting injectable antipsychotic medication in TriCare: The formulary for TriCare, the third-party payer for health care for military members, retirees, and their family members, includes only the long-acting injectables haloperidol and fluphenazine decanoate. Psychiatric patients may require an atypical antipsychotic for their long-acting injectable because a conventional (first-generation) antipsychotic is either not recommended or contraindicated. The Assembly action paper requests APA to appeal to TriCare for formulary coverage that includes an appropriate balance of conventional and atypical long-acting injectable antipsychotic medications.

• Educating members and the public about the psychiatric effects of racism: The Assembly approved an action paper that asks APA to enhance membership and public education about the mental health effects of racial discrimination, microaggressions, race-based violence, and racially motivated mass killings through curricular guidelines for medical schools, residency training, and continuing medical education programs, as well as media outreach. The action paper further asks that the index of subsequent versions of DSM refer to race and racism content currently present in sections and subsections.

• Defending the Public Service Loan Forgiveness program: The Public Service Loan Forgiveness (PSLF) Program was initiated to mitigate medical school loan burden by allowing students to select specialties without debt as a consideration. It also increases access to care for underserved populations by encouraging young physicians to practice in a nonprofit, public system. The PSLF program is of great importance and concern to resident and fellow members and early career psychiatrists, many of whom have already accepted positions and begun loan repayment plans with the intent of qualifying for this program. As of May 2017, over 500,000 people were on track to receive this benefit. However, the education budget proposed by President Trump in May 2017 included a provision to end the PSLF program. The Assembly approved an action paper asking APA to support the continuation of the program and make its defense an advocacy priority as an access to care issue. It also asks APA to partner with other medical societies to achieve this goal.