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Blue Cross denied necessary coverage to some members, OHIC finds

PROVIDENCE, R.I. (WPRI) -- Blue Cross & Blue Shield of Rhode Island will pay $5 million after incorrectly denying medical benefits for some members, state officials said Monday.

The Office of the Health Insurance Commissioner (OHIC) released a report evaluating Blue Cross's compliance with laws and regulations relating to coverage of mental health and substance use disorder benefits.  

The commission's officer said its review of the insurer's records shows multiple examples of patients being denied necessary coverage.

According to the report, OHIC found Blue Cross's process for approving coverage to be “clinically inappropriate.”

The report also shows Blue Cross “did not properly consider patients’ welfare and safety.”

"For example, a psychotic patient displaying observable symptoms of being an active danger to self and others was found to meet criteria for admission for treatment in a residential setting, yet was denied treatment based on a generalized exclusion criterion that 'the patient can be treated at a lower level of care,'" the report noted.

OHIC reviewed a random sample of 444 cases, most from 2014, according to the agency.

A spokesperson for Blue Cross said the insurer "disagrees with the way the report characterizes our conduct ... and we strenuously deny any wrongdoing or violation of law."

"I don’t believe any insurer has done more to improve the behavioral health landscape in Rhode Island," Dr. Matthew Collins, Blue Cross's vice president of clinical integration, said in a statement. "Our efforts predated this report and will continue long after."

Collins said Blue Cross has implemented "a bundled payment model" for mental health treatment, and said that as of Aug. 1, "prior approval is no longer needed for in-network mental health or substance use disorder services." He also said the insurer will equalize copays and coverage for outpatient behavioral to match primary-care visits in 2019.

Instead of facing a penalty, Blue Cross has agreed to pay $1 million each year for the next five years into a new fund created by OHIC at the Rhode Island Foundation. The fund will be used to improve access to treatment for people with mental health and substance use disorders, according to OHIC.

OHIC said it is also reviewing the policies of UnitedHealthcare, Neighborhood Health Plan of Rhode Island and Tufts Health Plan for future reports.

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