11/04/2020

District court issues injunction against UBH for failure to cover MH/SUD

Judge Joseph Spero of the United States District Court for the Northern District of California issued a remedies order in Wit v. United Behavioral Health that included:

1. 10-year injunction requiring UBH to exclusively apply medical necessity criteria developed by non-profit clinical specialty associations;
2. appointment of a special master;
3. training of UBH in the proper use of court-ordered medical necessity criteria; and
4. reprocessing of nearly 67,000 mental health and substance use disorder benefit claims.  

The ruling comes after the Court, in a February 28, 2019 decision found United Behavioral Health, the country’s largest managed behavioral health care organization, illegally denied coverage for mental and substance use disorders based on flawed medical necessity criteria. 

These denials impacted more than 50,000 UBH enrollees, and  involved 67,000 claims for coverage across four states: Connecticut, Illinois, Rhode Island and Texas. This is the first time a major insurer has been found to be relying on improper guidelines as a basis for denying health care services. In its February decision, the Court found “[m]any mental health and substance use disorders are long term and chronic. While current symptoms are typically related to a patient’s chronic condition, it is generally accepted in the behavioral health community that effective treatment of individuals with mental health or substance use disorders is not limited to the alleviation of the current symptoms. Rather, effective treatment requires treatment of the chronic underlying condition as well.” 

This ruling is expected to have significant implications for the way mental health services are handled by plans. UBH will have the opportunity to appeal the decision to the U.S. Court of Appeals for the Ninth Circuit after a final judgment is entered.   

Brooke Wolf, MD, chair of OPPA's Private Practice Committee, and other members of the committee have worked tirelessly for years to implement some type of oversight in Ohio, that goes beyond the Ohio Department of Insurance's current procedures for appeals, to review these types of denials by insurance companies, claiming that plans do not follow their own medical necessity criteria. OPPA has been fighting for enforcement of the parity law for many years. This remains a priority for OPPA and APA.