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By Ken Hausman
The managed care industry may be introducing another new and troubling wrinkle that interferes with the way psychiatrists practice their profession. At least one major managed care firm has begun denying insurance coverage for psychiatrists' treatment of dementia, regardless of the fact that dementia is, and has long been, a DSM diagnosis.
Psychiatrist Robert Kohn, M.D., of Providence, R.I., has been notified by a major insurer that coverage was denied for all 20 patients he diagnosed with a primary dementia from the middle of May through the end of August.
The denials were not for psychotherapy visits-a frequent target of managed care executive-but for visits focused on medication management, most of them taking 15 minutes.
The managed care firm responsible for this decision was United Behavioral Health (UBH), a mental health carveout that has a contract with its parent firm, the general medical insurer United HealthCare, to manage mental illness treatment at Butler Hospital in Providence. United is one of the nation's largest insurers and operates Rhode Island's biggest HMO/PPO.
Kohn is a geriatric psychiatrist at that hospital and an assistant professor of psychiatry at Brown University. He is also the Rhode Island Psychiatric Society's deputy representative to the APA Assembly.
"The redefining of dementia as not a psychiatric diagnosis treated by psychiatry is most bizarre," Kohn emphasized. "This is a primary condition that a geriatric psychiatrist treats and is specifically trained to treat."
The irony of this situation, he noted, is that at least one managed care organization seems to have decided to limit the number of physicians who can be reimbursed for treating Alzheimer's disease at the juncture where research is beginning to provide the first tools to treat that form of dementia.
Adding to the senselessness, Kohn said in an interview with Psychiatric News, is that UBH had authorized the visits in question, but then proceeded to deny insurance reimbursement for them. The company also sent notices to the patients informing them that it had denied insurance coverage for these visits.
This patient notification has added a potentially disturbing element to the problem. Geriatric psychiatrist Luisa Skoble, M.D., a colleague of Kohn's at Butler, submitted to UBH a treatment authorization request on which she had indicated her suspicion that a patient's symptoms suggested she was suffering from Alzheimer's disease. The company denied coverage for Skoble to treat the woman and sent a claim-denial notice to the patient at the same time it sent one to Skoble. This was the way in which the patient learned that she might have Alzheimer's disease, Skoble told Psychiatric News.
Kohn stressed that he has "no vested financial interest" in getting the insurers to reverse their denials of reimbursement for Alzheimer's care. "I am a hospital employee, so I get paid regardless," he said. He also stated that the actions he took to investigate the problem and alert colleagues to the situation were undertaken on his behalf and not that of the hospital.
Startled by the first of the denials, he noted that as soon as they came to his attention, he checked to see whether the hospital was at fault for omitting or incorrectly filling out forms required by the insurer. He quickly learned that the hospital was not to blame for the situation.
Further investigation and correspondence with the insurers revealed that a squabble between the main insurer and its contracted carveout company centering on financial self-interest was at the root of the problem, Kohn explained.
It appears that UBH did not want Alzheimer's and other dementia treatment coverage to come out of the pot it uses to pay psychiatric benefits. It decided that caring for people with organic mental disorders was more appropriately the domain of neurologists, internists, or general practitioners and should thus be covered by the company that insures all nonpsychiatric care, United HealthCare. "They're playing ping-pong with this issue," Kohn said with disgust.
He noted as well that his neurologist colleagues have not had to confront such reimbursement denials when they treat patients for Alzheimer's disease, since they do not have to forward their patients' bills to a carveout company such as UBH.
Skoble took her complaints about the insurers to the Rhode Island Department of Health, which in turn pursued the matter with United.
The insurer responded by explaining that the denial of Alzheimer's care by the mental health carveout subsidiary is not a new policy development. "Financial coverage of authorized services for persons with organic diagnoses such as Alzheimer's disease is the responsibility of United HealthCare, not UBH," according to the response from United HealthCare Senior Medical Director, Anthony Kaziauskas, M.D., to the Rhode Island Department of Health. "UBH has established processes whereby it will either approve coverage on behalf of United HealthCare or coordinate with United HealthCare to provide appropriate authorization."
He indicated that UBH would manage benefits for treatment of organic mental disorders, including Alzheimer's disease, but United, its parent company, would pay the claims.
UBH's medical director, Ann Davidson, M.D., acknowledged that it denied coverage because it is not responsible for paying organic disease claims. She also admitted that the denial letter "should have been clearer with regard to coverage being available," and "in retrospect" its decision to send the patient a claim-denial letter, especially one that referred to the physician's diagnosis of her condition, was a poor one.
"After a careful review of this situation, UBH identified that we could have better served the member by leaving the member out of the communication process between the provider and UBH."
The so-called resolution of the situation has not satisfied Skoble. "This is another pain in the neck" inflicted by the managed care industry, she said, "and it remains to be seen whether this plan will work."
Kohn has had similar reimbursement claims denied since the companies indicated they had resolved their spat.
Anecdotal reports of similar treatment denials are beginning to appear in other states as well. Private insurers as well as the federal government cannot seek shelter in the argument that they failed to understand that a dementia component accompanies Alzheimer's disease, said Betsy Beckwith, director of government relations at the American Association for Geriatric Psychiatry (AAGP). "It's just a matter of money."
There is still "a huge bias against psychiatric treatment," but hiding underneath that bias is the fact that treating the psychiatric components of Alzheimer's disease costs insurance companies a great deal of money and will be even more expensive as the U.S. population ages and people live longer in the coming decades, Beckwith pointed out.
A position statement the AAGP adopted last year emphasizes, "Treatment of psychiatric morbidity [in Alzheimer's disease] is medically necessary to alleviate patient distress, reduce disability, diminish caregiver burden, delay institutional care, and enhance quality of life. Patients with AD and other dementias should therefore have access to ongoing psychiatric care during the course of their illness; and all health plans and insurers should ensure access to and coverage for psychiatric treatment commensurate with other medical treatments."
At press time APA's Council on Aging was scheduled to discuss the matter. In May the Assembly voted to ask that the council "develop a strategy to increase the access of people with Alzheimer's disease and other dementias to psychiatrists." The Assembly plans to revisit the issue at its November meeting.
Council on Aging Chair Christopher Colenda, M.D., said the problem stems in part from the "conceptualization of Alzheimer's disease. This is a classic case of a neuropsychiatric illness; that is, it's a neurological illness that has multiple psychiatric problems that psychiatrists are expert at treating."
Colenda added that APA has yet to address adequately the issue of how psychiatric services are delivered to older Americans under Medicare managed care.
"Getting in on the ground floor of this discussion is critical for American psychiatry," he said.
A troubling consequence of battles between insurers, like the one in Rhode Island, is that patients and their families will rapidly conclude that dementia treatment is simply not available to them, Kohn added. In fact, neither he nor Butler Hospital will turn away any such patient regardless of the status of their insurance coverage. "We will not take any steps that will impede care, but the insurance company is frightening people."
The Web address for the American Association for Geriatric Psychiatry is www.aagpgpa.org.