Is there still a role for behavioral health pre-authorization?
Supporting workforce behavioral health has long been a priority for employer health plan sponsors and, as we’ve reported, over the past few years many have expanded EAP services and added other behavioral health resources. Some further actions were prompted by the sweeping mental health parity rules issued in 2024. These rules aimed to improve access to Mental Health and Substance Use Disorder care through more robust provider networks and fewer and less restrictive pre-authorization requirements for individuals seeking treatment. For certain behavioral healthcare services, however, pre-authorization requirements serve to protect not only the plan, but the patient, and may be worth retaining.
How behavioral health pre-authorization can protect patients
Behavioral health pre-authorization is used by health insurance companies to review if treatments for mental health and substance abuse disorders are medically necessary prior to the provision of services. The request for prior authorization includes clinical rationale for the request, the specific treatment being planned and the credentials of the treating provider. The carrier’s clinical team reviews the request against established medical criteria and guidelines based on evidenced-based research, best practices, and such resources as the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), International Classification of Diseases (ICD), American Society of Addiction Medicine (ASAM), and Level of Care Utilization System (LOCUS). Medical care guidelines such as InterQual or Milliman are used to aid the carrier’s clinical team in assessing the request for medical necessity. If an inconsistency is identified, the carrier’s medical director and the treating physician will discuss the clinical information and the treatment plan. The peer-to-peer consultation can result in agreement on the original treatment request, an alternative treatment plan, or, in some cases, denial of the requested treatment. If the requested treatment is denied, appeal rights are explained.
In this way, pre-authorization aims to ensure proposed treatments are evidence-based, aligned with the patient’s diagnosis, and the most appropriate level of care for the patient’s needs. Importantly, services that result in certain restrictions to a patient’s independence, such as inpatient and residential treatment, are approved only in situations that require these approaches to manage a patient’s condition safely and effectively. The process also serves as an opportunity to support care coordination by connecting patient’s treatment providers, referring the patient for case management services, and planning for aftercare treatment.
From the perspective of payers and purchasers, behavioral health pre-authorization supports cost management by preventing unnecessary or excessive treatments. Further, pre-authorization is a tool for preventing fraud, waste, and abuse by verifying that services are appropriate and occurring as outlined in the treatment plan.
The impact of the Mental Health Parity and Addiction Equity Act on pre-authorization
Since 2009, the Mental Health Parity and Addiction Equity Act has required self-funded and fully insured group health plans that cover MH/SUD benefits to do so in parity with covered medical benefits. MHPAEA generally prohibits financial and other quantitative limits as well as nonquantitative treatment limitations — like preauthorization — on MH/SUD benefits that are more restrictive than what are imposed on medical benefits. This has resulted in the streamlining of pre-authorization requirements. For standard outpatient services, such as weekly therapy and medication management, pre-authorization requirements have been eliminated.
While to providers and patients, pre-authorization can be perceived as a barrier to accessing care, there is support for certain behavioral health services to require pre-authorization. For example, Electroconvulsive Therapy (ECT) is a treatment for treatment-resistant depression. ECT carries risks including memory loss, confusion, physical side effects, prolonged seizures, and general risks associated with anesthesia, so guidelines advise approval of ECT only in cases where anti-depressants are not effective. From the insurer’s perspective, ECT is a costlier treatment than common pharmaceuticals prescribed to treat depression and should therefore only be approved after other courses of treatment have failed. Another example of services often requiring pre-authorization is Applied Behavioral Analysis (ABA), an intensive therapy (often 20-40 hours per week) for the treatment of Autism Spectrum Disorder (ASD). The pre-authorization process for ABA can help ensure quality of care and clinical appropriateness of the planned intervention, while ongoing clinical reviews ensure treatment plan adherence and monitoring of the patient’s response to treatment. From the insurer’s perspective, ABA therapy can be susceptible to fraud, waste, and abuse with instances of “bad faith” actors submitting false claims for services not provided, fraudulently inflating the number of hours services were actually provided, and/or billing exorbitant rates for services provided.
Ensuring that pre-authorization processes do not result in barriers or delays to accessing care
While behavioral health pre-authorization has a role in protecting both the patient and insurer, the pre-authorization process must be applied timely, consistently, and clinically appropriately to be helpful. Delays or the denial of services that are medically necessary and clinically appropriate for a patient’s condition can lead to the worsening of symptoms and deterioration of a patient’s health, especially in cases involving suicidality and substance use disorder. Employers should be selective in choosing to work with plan administrators with a reputation for clinical integrity, the active involvement of the Medical Director, and adherence to mental health parity regulations. Employers can proactively and regularly review claims data and denial rates for behavioral health services and may elect to conduct third party audits of utilization management processes for adherence to best practices.
Rising utilization of behavioral healthcare since the pandemic is a testament to the efforts employers have made to increase access to care and reduce stigma in seeking health for mental health problems. There is no contradiction in also taking a thoughtful approach to behavioral healthcare pre-authorization as a way to protect patients as well as plan resources.
