In the News and Updates

NEWS: End Clawbacks for Mental Health Treatment

Bill limiting insurance clawbacks is key step toward addressing access to mental health care

BOSTON, MA – Today, private mental health clinicians organized through SEIU Local 509’s CliniciansUNITED campaign are testifying before the Joint Committee on Financial Services in favor of legislation to limit retroactive claims denials by insurance companies. This practice, known as clawbacks, is in effect a subtle way for insurance companies to deny critical behavioral health care.

Currently, insurance companies can recoup their payments to a clinician months, or even years, after a therapy session takes place and is paid for, even though therapists secure prior approval from health insurance companies before treating their patients, and then adhere to billing deadlines (usually 60 or 90 days after each session takes place). No similar deadline exists for insurance companies. As a result, companies have demanded that private mental health clinicians pay back thousands of dollars for services rendered years ago in good faith.

The financial burden and uncertainty created by unlimited clawbacks has a chilling effect on therapists and is a limiting factor on their ability to treat patients. More and more clinicians are choosing to leave insurance panels because they find the requirements, the reimbursement rates, and retroactive claims denials too difficult to accept. If there are fewer therapists accepting insurance, people seeking mental health and substance abuse services have a harder time finding qualified therapists to work with at fees they can afford.

“In order to tackle the crisis in access to affordable mental health care, we have to address the insurance practices that are limiting providers’ ability to treat their patients,” said Erica Kirsners, a clinician and social worker in Brookline. “We clinicians treat our patients in good faith and in accordance with the insurance information we have.  Insurance companies should also have to act in this good faith and in the spirit of our mental health access laws.”

CliniciansUNITED supports legislation introduced by Representative Jim O’Day and Senator Michael Rodrigues (H.2193/S.582) that would limit insurance companies to a six-month window for retroactive claims denials.

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CliniciansUNITED is a multidisciplinary group of behavioral health clinicians who are associate members of the Massachusetts Human Service Workers Union, SEIU Local 509. Together, we are fighting to ensure each and every Bay State resident has access to quality, affordable mental health services — and to bring about the fair reimbursement policies and practices needed to make universal access possible.

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CliniciansUNITED in Commonwealth Magazine

An op-ed highlighting the need to limit clawbacks on mental health services, signed by CliniciansUNITED Executive Committee member Erica Kirsners, ran in Commonwealth Magazine.

Clawbacks threaten mental health services

Measure would put limit on insurance companies’ reach

IMAGINE BEING WORRIED sick, struggling to find a mental health clinician to treat your 12-year-old child who is so anxious that he has not been able to go to school for two weeks.  You’ve called dozens of private mental health clinicians and treatment centers, day after day, only to hear that they are full and not accepting new patients.

Imagine being a new mother suffering postpartum depression, unable to care for your infant, and unable to get treatment.

Both of these situations are unimaginable tragedies, yet increasingly common here in the Commonwealth, as affordable access to mental health and substance abuse services continues to decline. Perhaps even more tragic is that health insurance company practices are partially responsible for this situation.

One of the major problems clinicians have to deal with is retroactive claims denials, also called clawbacks. Insurance companies can recoup their payments to a clinician months, or even years, after a therapy session takes place and is paid for. Therapists secure prior approval from health insurance companies before treating their patients, and then have to adhere to billing deadlines (usually 60 or 90 days after each session takes place). No similar deadline exists for insurance companies.

Most of the clawback stories we have heard involve insurance companies discovering months – or more often, years – after the fact that they were not actually the insurance of record when the treatment took place. So, even though the therapist called the insurance to make sure their new client was eligible for service, and even though the insurance authorized the treatment, and even though the therapist was paid for the service by the insurance company – still, months or years later, the insurance company might discover they had made a mistake and demand the money back.Insurance companies are also able to demand to see all of a clinician’s files for a particular client, and can recoup payment if the files do not follow their particular guidelines. It’s like if your employer could take back paychecks you deposited years ago, just because you forgot to endorse the checks.

Handling insurance for MassHealth members has additional complications, and this makes it difficult to treat those very patients for whom the Commonwealth needs to expand access to mental health services.

One colleague of ours in private practice received a letter in the mail from an insurer, demanding $27,000 back. According to the Bureau of Labor Statistics, that amount is over half of the median salary of mental health practitioners and counselors. Clawbacks have led to gaping budget holes for the more than 80 community-based mental health and treatment provider organizations in Massachusetts.  One South Shore center recently reported clawbacks totaling over $137,000.

The fear of an insurance company retroactively demanding such massive payments has a chilling effect on private mental health clinicians and treatment centers alike – many of which are small businesses. When we discuss the many factors driving down access to mental health care in our state, look no further than these business practices. They are effective, subtle ways for insurance companies to deny critical behavioral health care.

Massachusetts must join over half of the country in passing legislation to protect health care providers from this practice of clawbacks. This session, state Rep. James O’Day and Sen. Michael Rodrigues have introduced a measure that would limit insurance companies to a six-month period for recovering payments for services already completed. It is a critical step toward addressing the grossly unfair business practice of clawbacks and leveling the playing field between mental health clinicians and insurance companies. Insurances should have to adhere to the same timelines and rules that they require of providers.

Our colleagues provide crucial mental health and substance abuse services day-in and day-out, in good faith and in accordance with the best insurance information available to them at the time. Insurance companies routinely violate this good faith and the spirit of our laws when they claw back payments from providers.

Massachusetts can and must do better if we are to address the crisis in access to mental health and substance abuse care.

Erica Kirsners, LICSW, is a clinician and social worker in Brookline. She is a Co-Chair of CliniciansUNITED Executive Committee, a campaign of SEIU Local 509.Vicker DiGravio is the President and CEO of the Association for Behavioral Healthcare, a statewide association representing more than 80 community-based mental health and addiction treatment provider organizations. 

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Boston Globe Editorial | Mandate treatment, funding for mentally ill

Gerry Hill, father of David, an Eastham man suffering with mental illness who was shot and killed by police.

Gerry Hill, father of David, an Eastham man suffering with mental illness who was shot and killed by police.

NANCY CHIERO WAS as devoted as she was patient with her son Lee. The 35-year-old Uxbridge man had spent his life struggling with psychotic delusions, which would periodically send him to the emergency room for a prescription for medications. Those brought a brief respite, but Lee, who lived in his mother’s basement, would soon cycle off the meds and the visions would return. In 2007, caught in the grips of paranoia, he pushed her down the stairs and fatally stabbed her in the eyes — capturing the murder on videotape.

The story of the Uxbridge mother and son is emblematic of the state’s failed policies for treating those with serious mental illness. In a powerful series called “The Desperate and the Dead,” the Globe’s Spotlight team chronicled decades of tepid response, persistent underfunding, and governmental neglect that has thrown mentally ill patients into the streets and left families, police, and ER doctors with an enormous burden of care.

Since 2005, the series reported, more than 10 percent of all state homicides in which a suspect is known were allegedly committed by people with a history of mental illness or its clear symptoms. The Globe built a first-ever database of such cases; the numbers show that over the past 11 years at least 139 people in Massachusetts have died violently at the hands of a person with a diagnosed mental illness, or strong signs of one.

The arc of mental health care was supposed to be different, especially in the Bay State, where Frederick Wiseman’s shocking 1967 documentary, “Titicut Follies,” exposed humiliations inflicted on patients at Bridgewater State Hospital for the criminally insane and prompted pledges for change. State officials moved to shut down mental hospitals, with the aim of placing patients in more humane community clinics. The number of inpatient psychiatric beds in the state declined to 671 as of last year, from a peak of 23,560 in 1953, according to Spotlight.

But that robust system of community care never materialized. State officials slashed funding for inpatient mental health care by more than half from 1994 to 2013, at the same time that some treatment was being farmed out to private companies and nonprofits. But nearly a third of community mental health providers in Massachusetts reported closing clinics from 2013 to 2015, including the sort of intensive programs that could have benefited Nancy Chiero and her son.

Closing the gaps left by the legacy of deinstitutionalization is, front and center, an essential job of government. Cities like San Antonio provide a model, with aggressive funding of a system to handle psychiatric and substance abuse crises and move people from jails and ERs into treatment, Spotlight reports. There are other signs of progress in Massachusetts: In 2015, the state received nearly $1 million in federal seed money intended to establish pilot community clinics. And Governor Charlie Baker’s administration has put $41 million into MassHealth reimbursement rates — as private insurers seem to be fleeing in droves.

Finally, change is needed in state law in order to protect families, friends, and the public from mentally ill patients who pose a danger to others. Massachusetts, with its strong support for civil liberties, is one of only four states without a law that allows courts to compel patients with a history of noncompliance to undergo treatment. Such “assisted outpatient treatment” laws have led to better health outcomes in other states: patients are escorted to settings where they receive required medications. And while psychiatric medications can cause unwanted side effects — and research sometimes seems stuck in another era — they can also be effective in quelling symptoms.

It’s important to note that the vast number of those with mental illness are not violent, and feel stigmatized by any broad-brush approach. But legislators could couple the law with more funding for community clinics, as well as education and training. It could ultimately help patients like Lee Chiero and those who love them.

Read the full editorial from The Boston Globe.

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CliniciansUNITED In The Boston Globe’s Spotlight

On Sunday, August 28th, The Boston Globe printed their latest installment in their Spotlight series on mental health care in Massachusetts. They turn their attention to the underfunding of mental health services and cite our 2015 study, The Challenges of Private Practice: A Study of Clinicians’ Experiences Providing Mental Health Care in Massachusetts.

Click here to read the article. Click here to read the study.

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