Insurer and Third Party Provider Panels are long time used gimmicks to deny and delay services to consumers seeking
rightfully entitled to mental health services. We are sure that every clinician has received the,
Sorry our panel is full
letter from insurers and forced to take
out of network payment or force patients to come up with a large copayment.
The rationale used by insurers that panels ensure quality of care is nothing more than a transparent ruse to delay and deny
access to care and to increase their bottom line for their investors. Panels also are another way to get around the requirement
in the Affordable Care Act that patients have access to mental health services.
Moreover, for those patients enrolled in Advantage Medicare plans, they have essentially denied both providers and patients the rights and legal access to services covered under Medicare by requiring providers in these plans to be on their panels. Medicare enrollees outside these plans are not required to only be treated by providers that are on a Medicare panel because there are no Medicare panels.
On March 20, 2019, Dr. David Reinhardt and I met with Congress representative, Alan Lowenthal, who represents the 47th District in California. We provided Representative Lowenthal with the following draft legislation that we believe will eliminate the way insurers use provider panels to deny and delay access to care. Lowenthal was very responsive to both the problems we presented and to the fix we provided. If and when this legislation gets to the phase where we need to have letters of support sent to legislators, we will ask for your support.
Reason Legislation Is Needed
Access to mental health care, which has been legislatively expanded, has largely been denied and delayed by insurers and third party administrators. Access is blocked by these entities by utilizing phantom panels and by limiting access to provider panels by qualified practitioners. Delays in processing applications also are common tactics to hinder access to treatment. The utilization of phantom panels, where these entities advertise large numbers of providers who have never been contacted or authorized to be on a panel, and is largely a marketing scam, has always been known but never addressed in legislation.
Limiting access to provider panels is framed by these entities as the need to maintain
quality services for
the insured. In essence, limiting consumer access to providers is a consumer "protection" practice. Application processing
times can take up to six months. Yet, to qualify to be on a provider panel, a practitioner only has to supply the entity with:
1. A copy of a valid unrestricted state license to practice;
2. A Copy of a doctoral degree and other credentials,
3. A copy of self insurance in a required amount.
Alternatively, applicants may be required to enroll in a credential verifying service that can extend the application process by several more months.
Thus, given that almost every clinician will be able to satisfy the above criteria, why is there a need or rationale to limiting the number of providers on a panel? Clearly, the only reasons are to delay, discourage and deny mental health services to consumers who need and require treatment. Limited panels result in consumers having to endure long waits to see a provider in their area or require consumers to travel long distances for treatment. Long waits and long distances result in many consumers simply abandoning treatment or terminating treatment after only a few sessions. Canceled appointments by consumers are not reimbursable. Insurers gain by not having to incur further charges, or no charges at all, as treatment is abandoned, canceled, or terminated. If a patient has to pay a large copayment, treatment maybe terminated earlier than what is best for the patient or even ever started.Fix
The fix for this problem and to allow access to services is a simple "stand-a-alone" legislation or an amendment to pending legislation. The draft language presented avoids any mention of "Any Willing Provider" and would not present any conflict with current ERISA regulations. Employers who have self-insured plans and who do not use third part administrators and do not utilize a provider panel, would be exempt from the legislation. Moreover, since Medicare and Medicaid programs require a long and extensive credentials verification process, our legislation would result in greater access to treatment and reduced costs associated with duplicative credentials verification. An expanded pool of qualified clinicians decrease consumer wait times for treatment and would significantly implement the mental health requirements of the Affordable care Act.Proposed Draft Language
A psychologist or psychiatrist who is authorized by Medicare and/or Medicaid
and who meets the current requirements of an insurer or third party panel, shall not be
excluded from any provider panel and shall be reimbursed at the current rates for their
practice classification. Employers who are self-insured and do not utilize a provider
panel shall be exempt from the requirements of this (LEGISLATION OR