Saturday, July 12, 2008

"Insurance/ managed care plans can use utilization review to manage a mental health benefit" = WE'LL GIVE YOU THE SERVICES WE WANT TO GIVE YOU

A western NC mental health advocate has stated as re: just what can the LME's do with their money?:

"There is no entitlement to services by people who do not receive Medicaid, and then only a list of specific services (therapy is not one of them.) The $$ given to the LME can be use any way they want to use it, put in any kind of model or service delivery service and they and they alone decide who gets the service and who does not."

You would think that NCPA would have something to say about this, but narry a word.

I've posted this to Madame Defarge before, about a week or so ago.

There is, however, now an additional component now, namely Item 1, which indicates that indeed, 3rd party payers can manipulate, via Utilization Review, just as the LME's have 'managed' therapy for any diagnosis as associated with state funded clients (this is what they manage, the 'working poor', w/ no health insurance), such that therapy is basically not available. See Item 1, immediately below.

Pay heed to what is in Cameron's document and speculate on what is 'in between the lines'.....(she presented this to NC psychologists who are members of NCPA a month or more ago):

1. Cameron, Executive Director of the NC Psychological Association, which is supposed to represent NC psychologists, has been mostly mum about NC mental health reform. This is waht Cameron has stated re: NC mental health reform:

"Insurance/ managed care plans can use utilization review to manage a mental health benefit."

In western NC, Smoky Mountain Center (SMC) LME Utilization Management department indicates that NO therapy Basic Services are available to state funded clients.

Community Support Services (CSS) are utilized under SMC LME for therapy services for state funded clients.

My experience is that NO therapy services will be provided or very minimally (a handful, literally, of sessions) with the stipulation that clients be forwarded into Meridian Behavioral Services (headed by retired SMC employee, ,Joe Ferraro).

The fact is that Meridian's W.R.A.P. classes, associated with Meridian's contract w/ SMC LME, in Haywood county, have very minimal attendance now ( a year ago there were 20 plus clients; today there are 2 clients in WRAP classes).

Meridian's contract w/ SMC LME continues thru next July.

This means that state funded clients will continue to be funnelled into Meridian's non existent Recovery Education Center which is associated with WRAP classes and that no therapy services offered by professionals will be available to state funded clients, the 'working poor' without health insurance, until this contract is finished (at the very least).

Thus, Meridian is paid for non-services, as per their capitated contract (assumably) while willing providers cannot obtain authorization in order to be paid for services they are willing to offer.

I sent a Freedome of Information Act request for a SMC LME Board 'packet', which should include minutes of the Board meetings for the past 2 years (this is what I have asked for) as associated with the Winston Salem Journal's (online) coverage re: public record information, this past week. I have heard nothing. I presume my request has been forwarded to SMC LME attorney.

This is what I sent:

What I want to know is how much Meridian Behavioral Services is being paid for their (assumably) capitated contract in order to cover lives----which are not being covered-----while other providers drum their fingers on the table awaiting authorization to see clients.

July 9, 2008

Dear Mr. Tom McDevitt (, Director of SMC LME:

I am requesting a copy of the SMC LME board minutes for the past two years (June, 2006-June 2008). Specifically, I am requesting a copy under FOIA as well as per NC statute (see below) which allows me to receive such information.

Thank you. I will be glad to pay the usual copying costs or you may send those records via my private fax machine at my home: 828 253 2066.

Please send that bill to: 168 Virginia Avenue, Asheville, NC 28806.


Marsha V. Hammond, PhD

Published: July 6, 2008

"....Under current law, members of the public may request a public record without having to explain their reasons for wanting to see it. The law is based on the basic philosophy that a public record belongs to the public...."

Furthermore, in western NC, WHN LME's utilization department headed up by Marsha Ring has stated that no more than 8 therapy sessions are allowable for any state funded client, regardless of diagnosis.

Personality Disorder diagnoses can be offered more than 8 therapy sessions IF there is also group therapy offered to those clients which utilizes Dialectical Behavior Therapy (cognitive psychology).

This is the second item of interest as re: Cameron's post:

2. "The parity law does not cover the State Health Plan PPO plans (BCBSNC---this is my parentheses information; everyone avoids calling The State Plan as associated w/ BCBSNC) ----a strategic decision because the PPO plans have a broader benefit and includes parity for substance abuse."

Apparently, BCBSNC struck a deal w/ NC State Legislature---which supposedly overviews them----- which allowed them to opt out of mental health parity in exchange for they providing 60/40 payment (the usual poor payment for mental health services wherein professional providers are paid 60% of the allowed fee e.g., for 90806, 45 min of therapy, they are paid approx $55 or at least that is what this doctoral level psychologist is paid) for diagnoses associated with drug or alcohol abuse/ dependency.


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