Court Ruling in Wit v. UBH Should be Upheld, Urges APA

Managed care organizations must use medical necessity criteria and assessment tools developed by nonprofit mental health and substance use disorder specialty organizations when making coverage-related determinations.That ’s what APA and seven other medical organizations told the United States Court of Appeals for the Ninth Circuit in afriend-of-the-court brief filed yesterday in the caseDavid Wit, et. al., v. United Behavioral Health (UBH). The brief is informed by a 2020APA Position Statement on Level of Care Criteria for Acute Psychiatric Treatment.UBH is appealing anOctober 2020 ruling by Judge Joseph Spero of the United States District Court for the Northern District of California ordering the company to re-process more than 67,000 claims for mental health and substance use disorder (MH/SUD) treatment, using level of care and clinical guidelines developed by nonprofit mental health and substance use disorder associations. Spero ’s injunction followed a2019 ruling by the same court that UBH had illegally denied those claims based on flawed medical necessity criteria.The 2019 ruling and the 2020 injunction are groundbreaking because managed care companies have traditionally created their own guidelines for level of care and medical necessity, factoring costs into the coverage decisions. “Such guidelines may lead to denial of coverage for treatment that is recommended by a patient’s physician and even cut off coverage when treatment is already being delivered,” acc...
Source: Psychiatr News - Category: Psychiatry Tags: APA friend-of-the-court brief insurance companies Judge Joseph Spero medical necessity mental health and substance use disorders Saul Levin United Behavioral Health Vivian Pender Wit v. UBH Source Type: research