MAAPPN responds to MA Attorney General report on Health Care Costs

MAAPPN expressed congratulations to the MA Attorney General for the report  on June 30th, 2015 identifying the impact of “historically low reimbursement rates” as undermining our states’ health care reform goals including access to behavioral health services and the impact on overall medical expenditures for consumers with behavioral health disorders.  In addition, the process of rate determination was taken to task as a possible parity violation.

In a letter to the AG, MAAPPN along with other Mental Health Coalition members stated: 
“We are concerned that the historically low reimbursement rates that you reference may in part be the result of a process of determining reimbursement rates for behavioral health services that are qualitatively different than the process used for setting reimbursement rates for medical and surgical services.  If this concern is valid, then we speculate that this may represent a violation of state and/or federal mental health parity laws.
We understand that your office has some responsibility with regard to enforcing mental health parity laws.  We urge you to consider whether to use your investigative powers to determine whether mental health parity laws are being violated with regard to how health plans, and their respective managed behavioral health organizations, are setting reimbursement rates for behavioral health services and to take whatever steps necessary to enforce these laws.
Again, we commend you and your Health Care Division for this important report.  We believe it is a vital step towards addressing behavioral health services access and understanding that increasing expenditures for behavioral health services is instrumental in containing overall healthcare expenditures.  We hope that you will follow up on the spirit of this report with appropriate investigative and enforcement actions, and we would be pleased to provide any assistance that may be helpful to your work on behavioral health issues.
MAAPPN has further suggested to the AG that they hold a “Listening Session ” with the Mental Health Coalition to further identify the our specific concerns about parity violations in rate setting.


Former MAAPPN C0-Chair is New Chief Nursing Officer at Arbour Hospital

Tedi P. Hughes, RN, MS, PMHCNS-BC, is the new Chief Nursing Officer for Arbour Hospital. Tedi is a seasoned clinician, leader, educator, and consultant in psychiatric mental health nursing.

Her experience ranges along the continuum of care: inpatient, PHP/ day treatment, outpatient therapy, and crisis. Tedi’s most recent role has been working as Director, Patient Care Services, for New England Baptist Hospital. Prior to this, she worked as a Director, Psychiatric Nursing, for Children’s Hospital. Tedi’s office is located at 49 Robinwood Avenue, Jamaica Plain and she can be reached at 617-390-1319 or

Tedi served as the Co-Chair of MAAPPN at a time when the organization was ‘reconstituting’ and developing its current mission. She was instrumental in creating the forward momentum that the organization needed and provided creativity and clarity during that time. MAAPPN Congratulates Tedi on her new position!


MAAPPN Lends Support to MHLA Legislative Priorities

MAAPPN plays an active role in supporting legislation from other MA mental health groups.   As a member of the Mental Health Coalition, MAAPPN has the opportunity to hear of the legislative priorities from the professional groups (the guilds), advocacy and other mental health policy groups.  Susan Fendell, Senior Attorney for Mental Health Legal Advisors Committee announced MHLAC’s legislative priorities for 2015-16 and has asked MAPPN’s support.  MAAPPN will be lending support and endorsement to the following initiatives:

Susan can be reached at  24 School Street, 8th Floor, Boston, MA 02108, 617-338-2345 x129, 617-338-2347 (fax)

DOI Issues Bulletin to Make Medical Necessity Criteria Easily Findable

November 4, 2014

Advanced Practice Psychiatric Nurses working in private practice or in health care facilities will welcome the DOI Bulletin that requires that private insurance companies make their medical necessity criteria findable and accessible on web sites by January 1, 2015.

The DOI announced these changes in today’s ‘Listening Session’ for Transparency of Medical Necessity Criteria.  While other DOI Listening Sessions have focused on the process steps in authorization, appeals and denials, today’s session was used to announce the release of Bulletin 2014-10.  Participants in today’s session included private insurance carriers, state agencies, providers and advocacy groups.  Transparency of medical necessity criteria has been a simmering issue between providers and carriers with complaints aimed at each other on both sides of the divide. Carriers complain that they have no access to the medical doctor or provider who knows the most about what is clinically necessary. Providers are critical of carriers who seem to make subjective denials of care without understanding the needs of the client.

The DOI while responsible for overseeing private carrier compliance with state and federal laws, also receives information, concerns and complaints directly from consumers, advocates, providers and other state agencies(such as the OPP).  The DOI’s intention with Listening Sessions is to clarify the issues, promote solutions and define strategies fair to all concerns.  In today’s session, opportunities were provided to the carriers to describe the changes they have made in transparency since the law went into effect on July 1, 2014.  Other stakeholders went on to discuss concerns about how far or limited the Bulletin goes in resolving conflicts associated with getting services and treatments approved for patients.

The issue of Proprietary (purchased) Criteria was also addressed and prominently mentioned in Bulletin 2014-10.  Proprietary criteria (i.e.McKesson Interqual)  is treated differently then other medical necessity criteria because of its commercial value to the carriers and its exemption from public sharing.  However, Bulletin 2014-10 states that proprietary criteria MUST be shared with providers as it is relevant to the particulars of a patient situation.  While not publicly shared and only shared as relevant to specific patient needs, this does represent a step forward. Still, proprietary data can present difficulties such as with subjective interpretation and provider access to full criteria documentation (especially in appeals situations).

Key Aspects of Bulletin 2014-10

Non-Proprietary Medical Necessity Criteria: 
Where the insured or prospective insured, health care provider is seeking non-proprietary criteria: 
  • Utilization review criteria, medical necessity criteria and protocols shall be made available to the public at no charge;
  • Carriers shall provide access to non-proprietary criteria and protocols by posting the criteria and protocols on a public website.
  • Carriers shall make such criteria and protocols available on a public website as soon as possible but no later than January 1, 2015.
  • Criteria and protocols posted on a public website must be easily accessible and up-to-date.
Licensed, Proprietary Medical Necessity Criteria:
 Where the insured or prospective insured, health care provider, Office of Patient Protection or the Division of Insurance is seeking licensed, proprietary criteria:
  • the carrier may limit the information provided to that which is relevant to the particular treatments or services identified by the insured or prospective insured or the services identified by the health care provider.
  • Access for OPP and the Division:  Carriers shall provide all criteria and protocols upon request to OPP and the Division free of charge, including licensed, proprietary criteria and protocols purchased by a carrier.
  • Any such licensed, proprietary criteria and protocols purchased by a carrier provided to OPP and the Division shall not be public records and shall be exempt from disclosure under the public records laws.
  • OPP and the Division may request the entire set of utilization review criteria, medical necessity criteria and protocols, and in response to such a request the carrier shall provide all requested documents.

Lingering Issues:  Questions and concerns remain going forward…

Participants identified that there are still issues with respect to details published in rejection letters, participant selection of criteria Panels and subjectivity  in interpreting criteria.

  1. Adverse Determination Letters:  when services are denied, what information goes into the letter?  How is the proper balance struck between publishing the specific particulars of the case (that another family member might see) or general statements about why there was an adverse determination?
  2. Criteria Development Panels: Who is represented on panels deciding criteria?, who is qualified, who is not represented, who is excluded?
  3. Subjectivity in Criteria Interpretation Risk:  Is criteria used narrowly or broadly? as a ceiling or a guideline? Who is making decisions on the phone and what happens when the decision is made without adequate information? Are service requests unfairly labeled as ‘futile’ and thus denied?and how can all involved in the process be knowledgeable and aware of criteria before they get on the phone ?

The DOI reminded participants that its authority is only over insured plans (not MASS health, self funded, out of state or government plans).  The DOI further emphasized that they intend to monitor the compliance of carriers to accomplish the public access by January 1, 2015 and to further monitor the key aspects of the Bulletin such as findability, the presence or absence of up-to-date information and consistent terminology across carriers.  The DOI remain open to filing further regulations should they be required.

Feedback is welcome to the attention of


MassEHealth: Effective and Proper Use of the Mass HIway Directory October 9, 2014

As Advanced Practice Psychiatric APRN’s we are involved in every aspect of professional care of our clients, including documenting care, protecting privacy and ensuring effective care collaboration and data sharing.  Look under the hood into the MassEHealth Initiatives and get familiar with how data is being used in everyday health care and how it relates to the larger issues such as the Affordable Care Act and Accountable Care Organization frameworks



Health Reform in Massachusetts 2012

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At State House ceremony, Governor credits broad coalition for making landmark law possible; Cites better care at lower costs, savings of nearly $200 billion over 15 years & increase in take home pay for workers, savings for families

Governor Patrick signs the health care reform bill in Nurses Hall at the State House. (Photo Credit: Eric Haynes / Governor’s Office) View full size photo.

BOSTON – Monday, August 6, 2012 – Governor Deval Patrick today launched the next phase of health care reform, signing legislation that builds on the Commonwealth’s nation-leading access to care through landmark measures that will lower costs and make quality, affordable care a reality for all Massachusetts residents.

“Today, we take our next big step forward. Massachusetts has been a model to the nation for access to health care. Today we become the first to crack the code on cost. And we have come this far together,” said Governor Patrick. “The law I have signed makes the link between better health and lower costs, that we need a real health care system in place of the sick care system we have today. What we’re really doing is moving towards a focus on health outcomes, and a system to reward that. We are ushering in the end of fee-for-service care in Massachusetts in favor of better care at lower cost.” (Read the Governor’s full remarks here.)

During a ceremony at the State House, Governor Patrick joined medical, business and labor leaders, caregivers and patient advocates, and legislators and policy makers, crediting the broad coalition for delivering on the promise of the Commonwealth’s 2006 health care reform law that expanded coverage to over 98% of residents, including 99.8% of children. The Governor noted that the first phase of health care reform, which the Patrick-Murray Administration successfully implemented, has led to more residents having a primary care physician, more businesses offering coverage and an increase in preventive care.

“Our Administration has worked to increase access to quality health care for Massachusetts residents, and we have built a strong partnership with providers, consumers, and other stakeholders to address the affordability of care within the system,” said Lieutenant Governor Timothy Murray. “We thank the state legislature and all who have been dedicated to working with us as we prepare for the next phase of health care reform, reducing the rising cost within our health care system and easing the burden on Massachusetts families, businesses, and residents.”

“By striking just the right balance, this bill will help slow the spiraling health care costs faced by businesses and individual consumers while also allowing the marketplace to grow and function,” said Attorney General Martha Coakley. “We are proud to be part of this first-in-the-nation effort and are prepared to ensure the law’s fair and effective implementation. I thank Governor Patrick for his leadership on this issue and applaud the Legislature, particularly the work of Chairmen Walsh and Moore, as well as Senate President Murray and Speaker DeLeo, for this landmark health care bill.”