Psychiatric care delay in spotlight

The Baltimore Sun

The Maryland Insurance Administration is investigating complaints that some psychiatric patients have been forced to wait hours - in some cases, several days - to be hospitalized because their insurance companies have not responded quickly when emergency room doctors called to verify coverage.The Baltimore health department has sent the state agency information about 10 cases in recent months in which patients endured long waits to be admitted to hospitals because their insurance companies could not be reached for approval.

"The emergency department is no place for someone with serious mental illness to spend days waiting for a call back from an insurance company," said the city's health commissioner, Dr. Joshua M. Sharfstein.

The insurance administration says it has launched an investigation seeking specifics about the cases and collecting information about patients, providers and insurers.

"We don't know if this can be something as benign as the providers, for whatever reasons, have an incorrect phone number ... or whether there is truly an issue here that the [insurers] are not answering the phone," said Karen Barrow, a Maryland Insurance Administration spokeswoman.

"We definitely take this complaint and all the complaints we receive very seriously," she said. "I can say it is being actively pursued."

Excessive delays are illegal under a state law, passed in 2006, designed to guarantee that insurance companies don't leave patients in limbo when they need psychiatric treatment. The law says insurers must be available around the clock and must respond to requests for preauthorization within two hours.

The insurance administration has the authority to fine insurers who don't comply with the law, Barrow said.

Insurance companies generally handle hospital admissions for psychiatric patients differently than they do for other seriously ill patients who arrive at an emergency room. Insurers tend to insist on preauthorization for psychiatric hospital care. Hospitals that provide care without the approval risk being stuck with the bill.

Kevin Kane, a spokesman with CareFirst BlueCross BlueShield, a company named in the city health department's list of complaints, said it works to respond to requests for hospital admissions within an hour. If it cannot, the company's practice is to authorize care, he said.

"As a matter of practice, we track how quickly and efficiently such preauthorizations are made," Kane said. "Based on that data, we are confident that with very few exceptions, preauthorization determinations are made within an hour."

Kane said the company has phone lines staffed around the clock and added the company would examine the cases listed in the complaints.

The complaints included in the health department's letter allege situations during nights and weekends in which calls to insurers by emergency department staff went unanswered. In some cases, patients who arrived on a Friday night seeking hospitalization spent the weekend in the ER. The letter does not include details of their illnesses.

The Maryland Hospital Association says such situations are not unusual. "We continue to hear complaints from hospitals about difficulties on nights and weekends getting timely response from insurers. Patients get stuck in the emergency department," said Pegeen A. Townsend, an association vice president.

Others agreed. "This has been going on for a while. It's not new," said Dr. Patrick Triplett, director of psychiatric emergency services at Johns Hopkins Hospital. He said he encounters the problem about once a month in the hospital's emergency room.

Triplett oversees admissions from the emergency room, which at Hopkins and elsewhere is often crowded. Additional patients waiting in emergency rooms strain already strapped resources, he said.

"If someone is in an extreme mental state, and then has to stay in a crowded, noisy emergency department, that's stressful," Triplett said.

Without the authorization, hospitals are left to foot the bill for patient care, said Suzanne Harrison, director of psychiatry at LifeBridge Health, which operates Sinai Hospital in Baltimore and Northwest Hospital Center in Randallstown. Hospital staff sometimes ask themselves later if they made the right choice.

"Did they do what was right for patient care, and risk not getting paid?" she said. "Or did they go on the financial side and let the patient sit there?" She said she and many health care providers err on the side of providing care.

Sheppard Pratt psychiatric hospital in Towson also has experienced such problems, said Bonnie Katz, a vice president. She said Sheppard Pratt has not been contacted by the insurance administration.

"My largest concern is I think that the system is designed for what works best for the third-party entities, these managed-care organizations, and not what's in the best interest of the patient and the people who are trying to provide care for the patient," she said.

Sharfstein said he encourages doctors and hospital staff to report problems to the insurance commissioner.

"What they're reporting appears to be illegal," Sharfstein said. "This should not be something that we accept as business as usual."

While the 2006 law was designed to prevent such problems, Harrison said few insurance companies have made changes to comply.

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