Who Decides Medical Necessity For Mental Health?   Massachusetts State Bill Challenges Notion

The recent article by Colin A. Young, staff writer for the State House News Service, reported on a Massachusetts  bill (H 1070/S 1093) adding to the definition of “medically necessary services” and challenges the notion of who decides medical necessity. Medical necessity criteria sits at the center of case and claim determinations. Laws, policies, and procedures evolve through time and the various administrations both locally and nationally.

Rolling out and implementing medical necessity criteria updates quickly and smoothly impacts payers and providers, especially when across the board legislative changes happen.

Massachusetts’s Bill (H 1070/S 1093)

Groups representing insurance plans and behavioral health service providers scrapped Monday over a bill that would give clinicians a greater say in determining medical necessity for mental health services, a decision typically made by the insurer. Click HERE to download the very brief MA House bill.

A bill (H 1070/S 1093) will add to the definition of “medically necessary services” the provision that, “Medically necessary services for mental health treatment shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.”

Who Decides Medical Necessity?

“As long as that definition is left in the hands of insurers, there is still a barrier to access to mental health services,” Susan Fendell, Esq., Senior Attorney, of the Mental Health Legal Advisors Committee, said.

“The interpretation of medical necessity criteria is too important to be left to insurance companies who do not have an intimate relationship with the patient, and we believe the patient and clinician are best able to determine medical necessity.” – Susan Fendell, Esq. Senior Attorney

The Joint Committee on Mental Health, Substance Use and Recovery, co-chaired by Flanagan, heard from Fendell and others who support the change, as well as opponents from the Massachusetts Association of Health Plans (MAHP).

Dr. Joel Rubinstein, who served as associate medical director of Harvard Pilgrim Health Care for about 20 years and now advises MAHP, said that many people think of medical necessity in simplistic terms while it, in fact, has “a number of dimensions.”

“Medical necessity actually deals with levels of care. The question becomes will they be treated in a hospital? Will they be treated in a day program? Will they be treated in outpatient psychotherapy?” he said. “Medical necessity includes a whole lot of things, a number of things that a provider, certainly I as a provider, couldn’t have spoken to.”

Sarah Gordon Chiaramida, vice president of legal affairs for MAHP, said the association has concerns that the bills would limit an insurance “plan’s ability to do medical management, and also care management on behalf of Medicaid members.”

Matteodo said the Flanagan/Khan bill would extend to mental health services something that the Legislature did for substance abuse treatment services in a 2014 law that afforded insurance coverage for up to 14 consecutive days of medically necessary substance abuse treatment and abolished the ability of health plans to conduct medical necessity determinations.

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Federal healthcare legislation shakes the industry on many levels, especially on the state level. Massachusetts  bill (H 1070/S 1093) adds language limiting input from payers. BHM’s reviewer network stays informed of regional changes and allows you to focus on patient care.  Click HERE and discuss how BHM’s expertise can keep your organization of medical necessity criteria changes and improve your metrics.