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Prior Authorization Less Likely to be Granted for Mental Health

Analysis  |  By Jay Asser  
   April 08, 2022

According to a study by the U.S. Government Accountability Office (GAO), patients face greater challenges with receiving approval for mental health services than medical services.

The demand for mental healthcare is on the rise, but even those with coverage are experiencing difficulties accessing services, a new study by GAO found.

One of those hurdles is prior authorization, which is less likely to be granted for mental health hospital stays compared with medical and surgical hospital stays, according to the study.

For the report, GAO interviewed federal officials and representatives from 29 stakeholder organizations representing consumers, health plans, providers, insurance regulators, and mental health and Medicaid agencies.

Sixteen of the 29 stakeholder organizations pointed to non-quantitative treatment limitations (NQTLs) used by health plans as causing delays in accessing mental health treatment or limiting time spent in treatment. Prior authorization, in particular, was highlighted as a challenge by representatives from most of the organizations.

"In some cases stakeholders said that health plans are applying these limits to consumers' mental health benefits in more restrictive ways than to medical and surgical benefits, which highlight ongoing mental health parity issues," the study stated.

Aside from mental hospital stays being less likely to be granted, other examples of prior authorization issues cited by the representatives in the report included:

  • Denial rates were slightly higher for inpatient pre-authorization for mental health services compared to medical and surgical benefits, according to officials from one insurance regulator
     
  • Private health plans and Medicaid plans said they wouldn't cover mental health inpatient treatment any longer, even if the physician determined that additional treatment was needed, according to representatives from a health system that provides mental healthcare

Whether it's in mental or medical healthcare, prior authorization continues to be a source of consternation. While physicians and medical groups agree that streamlining the administrative process can significantly cut down on delays and restrictions in care, implementing a regulated method brings its own set of challenges.

Related: 3 Facts and 3 Predictions for Prior Authorization

When it comes to mental health, however, the GAO report states that the parity laws in place should be requiring that mental health treatment is no more restrictive than coverage for medical or surgical treatment.

"Within their parity oversight responsibilities, the Department of Labor and the Department of Health and Human Services are taking steps to enhance their oversight of the use of NQTLs in mental health coverage, which, according to these officials, could improve access to mental health care," the study concluded.

Jay Asser is an associate editor for HealthLeaders.


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