Insurers ask for mental-health notes from patient sessions

Andy Marso
The Kansas City Star

KANSAS CITY – Susan Eyman, a psychologist in Lawrence, Kansas, told a patient last year that the patient’s insurance company had requested her notes from their therapy sessions as part of an audit of her billings.

Eyman said the patient was shocked. The notes included intensely personal things about trauma he had told her in strict confidence. He asked if she could assure the confidentiality of the notes once Blue Cross Blue Shield of Kansas had them.

“And I said, ‘No, of course not,’ “ Eyman said. “Of course I can’t. If you send this information out there, it’s out there.”

Eyman said she refused to turn over the notes and was forced to pay back thousands in BCBS Kansas reimbursements.

She’s is one of several mental health professionals who say they feel targeted by heavy-handed tactics that BCBS Kansas and its mental health subcontractor, Kansas City-based New Directions Behavioral Health, are using to limit costs at the expense of patients who need intensive counseling.

Mental health therapists say the audits and payment recoupments are having a chilling effect on their ability to treat people who need counseling either several times a week or for a long period of time.

They’re questioning whether they violate parity laws that require insurers to cover mental and behavioral health care the same way they cover medical care.

“It’s all about cost containment basically, and it’s not looking at and really honestly questioning what’s going on in this treatment that it’s taking this amount of time,” said Karen Bellows, a clinical social worker who does mental health counseling in Topeka.

Audits: The insurance company says the audits only apply to a small number of high-cost providers, and they’re used to determine whether the services rendered fit what was billed. Therapy notes and other documents provided for the audits are strictly shielded in accordance with medical privacy laws, BCBS Kansas spokeswoman Mary Beth Chambers said.

“We realize that claims analysis does not paint a complete picture, which is why we seek documentation to better understand the diagnostic complexity and why the provider believes a specific patient requires a significantly higher number of visits than the norm,” BCBS Kansas spokeswoman Mary Beth Chambers said via email.

Parity laws are also at the center of a federal lawsuit against Blue Cross and Blue Shield of Kansas City. Blue KC covers the two counties in Kansas, Wyandotte and Johnson, that aren’t in BCBS Kansas territory.

Angela Dailey filed suit against Blue KC and New Directions in a federal court in Missouri in December, alleging that they refused to cover her son’s treatment at a therapeutic wilderness program in Utah in 2015.

According to the suit, her son’s therapist recommended an inpatient program after the teen became “increasingly violent, engaging in self-harm, threatening suicide, drinking alcohol and not attending school.”

New Directions, which referred all questions to BCBS and Blue KC, said her son should receive intensive outpatient therapy instead.

Dailey enrolled him in the wilderness program anyway. He was then discharged to a therapeutic boarding school in Idaho for further treatment. New Directions also denied coverage for that treatment and denied Dailey’s appeal.

Dailey’s attorney, Candace Weatherford, said she would not comment while the legislation is pending.

Blue KC spokeswoman Kelly Cannon said the company takes all complaints seriously.

“Blue KC works with New Directions and our contracted providers to develop and maintain medical policies that are consistent with the latest evidence-based medical literature,” Cannon said in an emailed statement.

Consumer protections: Rick Cagan, the executive director of the Kansas branch of the National Alliance on Mental Illness, said those laws are routinely flouted, not only in Kansas but nationally. He said his group has talked to the Kansas Insurance Department about it, but enforcement is still lacking and he’s now talking to legislators about stepping in.

“I feel like until providers and policyholders make some more noise we’re just not going to get the consumer protection we need from our state elected officials,” Cagan said.

But BCBS Kansas said the parity laws themselves are what led to the audits.

The parity laws explicitly prevent insurers from imposing separate co-pays or deductibles for mental health, only covering a certain number of office visits or days of inpatient care, or requiring prior authorizations for mental health services.

Chambers said the audits began after BCBS Kansas moved away from those measures.

“We did make some changes two years ago to some policies and procedures to ensure that behavioral health benefits are administered in the same manner as medical services benefits, which was the goal of the mental health parity law passed in 2009,” Chambers said.

Chambers said the claims reviews and audits are meant to identify “notable differences” between providers and “reduce variations that do not result in better member outcomes.”

But the therapists said the audits don’t account for patients who need more counseling than others.

“They don’t care how disturbed people are,” Eyman said. “They don’t care what the level of distress. They don’t figure that in.”

They’ve brought their concerns to the Kansas Insurance Department.

But Julie Holmes, the director of health and life insurance for the department, said the department reviewed their complaints and found that the audits are in line with parity laws because BCBS Kansas has similar measures for medical and surgical providers.

Still, the therapists say the audits are violating the spirit of the law, if not the letter of it, and their practical effect will be the same as setting the hard limits the law explicitly forbids.

Tom Bartlett, a clinical psychologist in Topeka, said it seems like unless his patients are suicidal, BCBS Kansas doesn’t want him to see them more than once a week. Which might be enough to help them survive, but not enough to help them thrive.

“You’re probably going to find a lot more adult children with mental illness living in their parents’ house,” Bartlett said. “But if you’re the insurance company, that’s not your worry.”