Blue Cross Blue Shield Parent Company Sued Over Stringent Behavioral Health Guidelines

The parent company of Blue Cross Blue Shield plan providers in five states is being sued over allegations that it’s been denying behavioral health benefits to members due to overly restrictive guidelines, according to Law360.

The federal lawsuit seeking class action status was filed late last month against Chicago-based Health Care Service Corporation (HCSC). The complaint claims that HCSC denied coverage to a Chicago-area woman with depression, substance use disorder (SUD) and borderline personality disorder based on “faulty guidelines issued by MCG Health,” Law360 reported.

MCG Health is a Seattle-based provider of healthcare solutions, guidelines and analytics. Its guidelines are used by eight of the country’s largest insurers, according to the suit.

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However, the plaintif’s lawyers argue those guidelines are unnecessarily restrictive — and that they caused HCSC to deny the plaintiff coverage of residential mental health treatment, claiming that the services were not medically necessary.

Per MCG guidelines, residential treatment is only medically necessary for crisis stabilization or when a patient has acute symptoms, according to Law360. However, standards from the majority of professional groups “recognize that persistent and/or pervasive behavioral health disorders cannot necessarily be as effectively treated on a short-term or outpatient basis as they could be in residential care,” the suit said.

HCSC told Law360 it doesn’t comment on pending litigation.

The suit is in line with a recent trend of litigation taking aim at behavioral health parity.

It comes after a federal judge ruled last year that UnitedHealthcare’s United Behavioral Health used guidelines that were too restrictive in the coverage of thousands of substance abuse patients. Additional lawsuits have followed with similar success.

Washington, D.C.-based litigation firm Zuckerman Spaeder, who won the United Behavioral Health ruling, is also representing the plaintiffs in the HCSC case.

“This case will have wider repercussions than the United case because it goes beyond a single insurer,” D. Brian Hufford, one of the plaintiff’s attorneys, told Law360. “If we can demonstrate in court that the use of the MCG guidelines is improper, that hopefully will continue momentum in compelling changes in how insurers cover behavioral health services.”

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