Systemic barrier may be especially troublesome for those seeking behavioral, mental health services

BY: CAMALOT TODD, Nevada Current

Last year, Michelle McGuire, a psychologist and chief executive officer of Creative Behavioral Connections, a clinic dedicated to treating children with autism, worked 10 weeks straight. 

Her weekdays were filled with assessing patients for autism, developing treatment plans, and overseeing her clinic’s day-to-day operations. 

Her weekends were spent in an arduous battle with insurance companies. 

She’s one of roughly 460 licensed psychologists in Nevada, a state with 12.2 psychologists per 100,000 people, about a third of the national average, according to the American Psychological Association. Her waitlist for assessments is roughly two months and her waitlist for treatment is over a year. 

“The biggest issue is access to care. They don’t have access to quality care. They just don’t because there’s not enough providers, so they sit and suffer needlessly,” McGuire said. 

Every county in Nevada meets the federal requirement for a professional mental health provider shortage. While the shortage of providers plays a role in those waitlists, there’s also a systemic barrier between Nevadans health care — insurance companies not accepting mental and behavioral health specialists in their network.

Waitlists to see a psychologist for autism can be up to two years in Clark County and many providers aren’t able to accept any insurance, leading to an economic disparity between those who can afford to pay hundreds in cash for treatment and those who can’t, McGuire said. 

No. 1 reason for denial: “No network need”

The denial rate for mental health and behavioral health providers more than doubled from 5.79% to 13.95% in Nevada, according to the review of insurance denials by the Nevada Department of Insurance (DOI) for 2020 and 2021. Prior to 2020, the state did not track insurance denials. 

Insurance companies denying new providers isn’t just limited to mental and behavioral health specialists but other medical professions. In 2020, across all specialties, 324 providers were denied entry to insurance company networks in the state. In 2021, a total of 624 providers were denied. The count for 2022 has yet to be released.  

The top reason for denials was that the insurance company was “not accepting new care providers within specialty/region or no network need.” Companies cited that reason 61.6% of the time in 2020 and 51% in 2021, more than three times more than any other reason.

Both state and federal parity laws are designed to see that mental and behavioral health are treated equally to medical and surgical health care. The laws have provisions that ban or rein in higher copayments, separate deductibles, and stricter preauthorization or medical necessity reviews, but there’s little oversight to see if insurance companies are in compliance. 

An investigation of 30 health insurance plans and issuers by the U.S. Department of Labor, Health & Human Services, and the Department of Treasury found that all 30 were out of compliance with federal mental health parity requirements that are on the books.

Preauthorization requirements is the most common reason for companies being out of compliance with parity laws. The second most frequent reason is network provider admission standards, according to the investigation report. 

Every insurance coverage a mental health specialist like McGuire wants to accept, they have to go through a cumbersome credentialing or paneling process by which a board of doctors in an insurance company decides whether to accept a new provider. 

Only after a specialist is accepted into the network does the insurance company inform them of the reimbursement rate of their services. 

There’s no requirement that these boards have mental health specialists on them, and few do, McGuire said. 

The state Department of Insurance doesn’t play any role in overseeing why providers for specialties like mental and behavioral health are being denied credentialing or paneling by insurance companies, according to the DOI. 

Additionally, the DOI only regulates individual and small-group market plans which cover about 7% of the state’s population. The bulk of Nevadans have insurance through their employer, Medicaid, the Children’s Health Insurance Program, or Medicare, and Medicare Advantage plans. Parity laws do not apply to Medicare, and there are various exceptions and exemptions that apply to other forms of health coverage, according to a Kaiser Family Foundation report.

Thirty-five states have “Any Willing Provider” laws on the books, which require health insurance carriers to allow providers to become members of their network if they meet the carrier’s conditions.

Nevada isn’t one of them. 

Dr. Marc Kahn, dean of the Kirk Kerkorian School of Medicine at UNLV, says he and others are lobbying Nevada legislators to pass an “Any Willing Provider” law which would effectively prohibit insurers from denying qualified providers, but they anticipate an uphill battle.

“(They) are not universally supported,” he said. “A lot of the big groups don’t want them. They want exclusivity. A lot of the big insurance companies don’t want them because they want narrow options that limit their expenses.”

‘Hopeless process’

Under an insurance industry bureaucracy that is infamous to many consumers, a provider who works at two facilities could be approved by an insurance company at one but not the other.

Aimee D’Errico is a licensed marriage and family therapist and doctoral student fulfilling her practicum requirement under McGuire. At one of her jobs, she’s in the network for Blue Cross Blue Shield. But she can’t accept that insurance as an individual practitioner. 

Those seeking help must find an in-network provider who is accepting new patients and can see them in a timely fashion. It can be a herculean task, she said.

“It’s a hopeless process if they just call and call and call,” D’Errico said. “They’re already seeking services because something has gone wrong in their lives, and they’re at the point where they can’t handle it, and then to go through this process is so detrimental to the mental health problems.”

She and McGuire both said they often spend their weekends and evenings calling insurance companies for preauthorizations, fighting for reimbursements that cover the cost of treatment, or trying to convince insurers to allow treatment to continue instead of capping the number of sessions it will pay for.

The cost of treatment for mental health services varies wildly. Good insurance coverage may charge a $20 copay for each session, averaging roughly $100 a week for applied behavioral analysis treatment. Other insurers charge more, and McGuire estimates families can pay anywhere between $400 to $800 a month on average just for therapy if they can afford it.

“Sometimes, they just don’t get services if the family can’t afford the co-pay,” she said. “Here we are with providers who have open spaces but that can’t get credentialed because (the insurance companies say) there are too many providers. Yet we have waitlists.”

No comment. No enforcement

The Current reached out to major insurance companies in Nevada, including Medicaid, Aetna, Cigna, United Health, and Anthem Blue Cross Blue Shield about acceptance rates for new providers in the state for the last two years, if there was a cap on sessions, and if reimbursement rates differed between physical and mental and behavioral health services. 

Only Aetna responded.

“No mental health and behavioral health providers have been denied credentialing in Nevada in the last two years, and there are no caps on mental health and substance use disorder benefits,” the company said in a statement. “In addition, Aetna offers competitive reimbursement for face-to-face and virtual mental health care and performs periodic reviews to ensure rates are competitive.”

However, Aetna, Cigna, United Health, and Anthem Blue Cross Blue Shield have been fined for being out of compliance in states like Pennsylvania, Rhode Island, and New York where enforcement laws are on the books.

Nevada has not published any enforcement actions related to mental health parity, according to ParityTracker, a monitoring effort launched by a collaboration of national behavioral health advocacy organizations.

Because there’s no real enforcement or clarity on why a provider gets accepted or denied to be a part of an insurance panel, McGuire hypothesized that mental and behavioral health providers remain silent so their livelihood and the work they’re doing to help Nevadans aren’t impacted. 

She said she’s speaking out only because she’s successful enough in her practice. 

“If I stayed complacent, it would’ve eaten me alive,” McGuire said. “I can’t watch these kiddos suffer.”