April 12, 2024
The New York state budget is now 10 days late. On Thursday, the state Senate passed another extender and the Assembly is expected to come back today to act on it. This is now the fourth budget extender since the April 1 budget deadline. An extender passed earlier this week pushed the payroll deadline to Tuesday. One of the main issues yet to be resolved is a deal on Housing. Lawmakers continue to discuss tenant protections, tax breaks for developers and a wage deal between developers and construction unions to name just a few of the remaining sticking points.
The NYS Council continues to fight for a 3.2% COLA that is free of restrictions and for OMIG Audit Reform that will infuse fairness and balance into the audit process. For over 10 years we have led the fight for a commercial rate mandate that will ensure New Yorkers with this insurance can secure the services they need from community-based mental health and substance use disorder providers who can afford to serve them and we continue to push for an enacted state budget that includes this policy reform. In addition, we are pushing for permanency and expansion of the telehealth law that continues the availability of these services while opening up payment parity to FQHCs.
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HEADS UP!
It’s been less than two weeks since New York’s health department granted permission for registered and certified pharmacists to provide long-acting injection-based medications for the treatment of mental health and substance use disorders, effective April 1, 2024.
Here’s a link to the Website for the NYS Education Department and specifically, the Office of the Professions page that explains what registered and certified registered pharmacists can do and under what circumstances they can do it:https://op.nysed.gov/professions/pharmacist/frequently-asked-questions/Long-Acting-Injectable-Medication-Administration
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Just a friendly reminder that the last vesting period of the Healthcare Worker Bonus Program was 3/31/24 and the portal is open for submissions through 4/30.
Here’s the Portal: https://nysworkerbonus.health.ny.gov/#/
Here’s the page with the most recently updated FAQs:https://health.ny.gov/health_care/medicaid/providers/hwb_program/hwb_program_faq.htm
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Court revives UnitedHealth behavioral health algorithm lawsuit
NONA TEPPER, MODERN HEALTHCARE, 4/11
A federal appeals court has revived a proposed class action alleging UnitedHealth Group used an algorithm to more stringently review patient claims for substance abuse treatment compared with requests for medical or surgical procedures.
The patient, who is identified as Ryan S., can press claims against UnitedHealth and eight of its subsidiaries under the Mental Health Parity and Addiction Equity Act of 2008, a three-judge panel for the 9th U.S. Circuit Court of Appeals ruled Thursday. The 9th Circuit decision overturns a December 2020 ruling by the U.S. District Court for the Northern District of California, which found that Ryan S. failed to identify a comparable medical or surgical procedure for which UnitedHealth provides coverage and prove his claims had been categorically denied.
The District Court will now reconsider allegations that UnitedHealth breached its fiduciary duty under the Employee Retirement Income Security Act of 1974. The 9th Circuit last year revived a separate class action against UnitedHealth that makes identical allegations but during a different time frame. UnitedHealth has faced several lawsuits alleging it applies a different standard of review for mental health and substance abuse treatment claims than for other types of care. Previous rulings against the company established the legal standard for how the health insurance industry must develop behavioral health benefits.
UnitedHealth did not immediately respond to an interview request.
Ryan S. sued UnitedHealth in 2019, alleging he was improperly left with hundreds of thousands of dollars in medical bills because the insurer failed to cover most of his out-of-network substance use disorder treatments. The lawsuit cited a 2018 report by California state regulators, which found that UnitedHealth used a tool called Algorithms for Effective Reporting and Treatment to systematically review and deny mental health and substance use disorder claims but not other requests for coverage. UnitedHealth in court filings argued the regulator’s report is not relevant to Ryan S.’s complaint.
“Even if all those denials were independently valid, the mere fact that the reasons to deny coverage were identified only because the mental health/substance use disorder claims were subjected to an additional layer of scrutiny could violate the Parity Act,” 9th Circuit Judge Richard Clifton wrote in the opinion Thursday.
Ryan S. wants UnitedHealth to reprocess all substance abuse claims from 2017 to 2019 and return any profits it gained by denying the claims.
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For NYS Council Hospitals:
CMS pitches inpatient payment rule for 2025: 8 things to know
Here are eight things to know about the proposed rule:
1. Payment rate update: Under the proposed rule, acute care hospitals that report quality data and are meaningful users of EHRs would see a net 2.6% increase in payments for fiscal year 2025 compared to 2024. CMS said it anticipates the rate adjustment will increase total hospital payments by $3.2 billion.
2. Long-term care hospitals: CMS is proposing an overall increase of 1.6% — or $41 million — in standard payments to long-term care hospitals in 2025 compared to 2024.
3. TEAM model: CMS is proposing a mandatory model to test whether episode-based payments for five common, costly procedures would reduce Medicare expenditures while preserving or enhancing the quality of care. The “Transforming Episode Accountability” model could incentivize coordination between providers both during and 30 days after a surgery, and require referral to primary care services to support continuity of care and drive positive long-term health outcomes.
4. Essential medicines: CMS is proposing a separate payment to small, independent hospitals for establishing and maintaining access to a buffer stock of essential medicines.
5. SDOH: CMS is proposing adding new social determinants of health data elements in long-term care hospital quality reporting that would require hospitals to report elements on housing, food and utility stability, and access to transportation, which are factors that influence the resources required for their care.
6. Emergency preparedness: CMS is proposing a permanent streamlined data reporting structure for COVID-19, influenza and RSV, with additional reporting that could be activated during an emergency. The rule proposes a new attestation-based measure to assess whether hospitals demonstrate a structure, culture, and leadership commitment that prioritizes patient safety.
7. Maternal health: In an effort to improve access to quality care during pregnancy, childbirth and postpartum, CMS is seeking public comment on potential solutions that can be implemented through the hospital Conditions of Participation.
8. Comment period: CMS will accept comments on the proposed rule through June 10.
Read CMS’ fact sheet on the proposed rule here.
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Senators Aim to End ‘Fraudulent’ Ghost Networks with Behavioral Health Bill
By Morgan Gonzales | March 29, 2024
Inaccurate provider directories, known as “ghost networks,” can land patients with shocking bills and cause providers to miss out on potential patients. Ghost networks have increasingly come under fire by policymakers aiming to hold health plans accountable and protect patients.
A new bill, introduced last week by U.S. Senators Tina Smith (D-Minnesota) and Ron Wyden (D-Oregon), would crack down on health plans with inaccurate provider directories and seek to increase behavioral health providers’ in-network participation.
Called the Behavioral Health Network and Directory Improvement Act, the bill would require the federal government, as well as health plans, to conduct independent audits to determine the accuracy of health plans’ provider networks. This information would be posted publicly online, and if health plans fail to comply with network and directory adequacy requirements, they would be subject to civil monetary penalties (CMPs) issued by the Department of Labor.
“In the worst cases these ghost networks are essentially a fraudulent product, but health insurance companies continue to sell those policies for top dollar,” Wyden said in a statement. “Amid a nationwide mental health crisis, it’s outrageous how common it is for people in need of treatment to find that their health insurance is almost useless when they try to see a mental health provider.”
Health plans will be held to a higher network adequacy standard if the bill passes. Insurers would be required to consider the ratios of behavioral health providers to patients enrolled as well as waiting times for appointments, geographic accessibility of providers and the network’s ability to meet patients’ needs.
A summary of the bill called the Behavioral Health Network and Directory Improvement Act said that mental health professionals frequently leave health plan networks because of low reimbursement rates and insufficient network adequacy standards. The legislation aims to increase the number of in-network behavioral health providers by requiring federal agencies to establish parity standards to keep behavioral health reimbursements on par with physical health.
“By law, insurance companies should cover mental health just like they cover physical health, yet they’re still finding ways to dodge compliance and deny coverage to customers,” Smith said in a statement.
The legislation cracks down on health plans and requires additional work from providers. If passed, behavioral health providers must regularly update the information they submit to health plans, including timely information on whether they are currently accepting new clients.
The bill would provide consumers with additional protection by establishing state and tribal programs designed to educate people on their rights under the mental health parity law. It would also require health plans that maintain ghost networks to inform enrollees that they may be eligible for a refund if they see a provider who was inaccurately listed as in-network.
Ghost networks have previously been a target for legislators.
Another bill designed to combat ghost networks, the Requiring Enhanced & Accurate Lists of (REAL) Health Providers Act, was introduced to the Senate in October 2023 and was referred to the Committee on Finance. The REAL Health Providers Act would help protect seniors from the problems associated with ghost networks by ensuring Medicare Advantage online provider directories stay up-to-date.
The Behavioral Health Network and Directory Improvement Act has been endorsed by the National Alliance on Mental Illness (NAMI), The Kennedy Forum and the National Council for Mental Wellbeing, among other organizations.