By David LaGuerre
Two settlements address inaccurate provider lists and addiction-treatment denials related to Carelon settlement. Refund eligibility still requires review.
Carelon Behavioral Health must change its mental-health provider directories and substance-use treatment reviews under two Carelon settlement agreements announced November 10 by New York Attorney General Letitia James. The agreements also provide financial relief for eligible members who faced extra costs, according to the attorney general’s office.
Carelon manages behavioral-health benefits for more than four million New Yorkers through plans including EmblemHealth, Anthem Blue Cross Blue Shield, Independent Health and the Empire Plan, the office said. For Mohawk Valley residents, the practical question is whether Carelon handles their plan’s behavioral-health benefits and whether their situation meets the settlement’s requirements.
The announcement says Carelon will pay $2.35 million in penalties, fees and costs and provide up to $8 million in restitution for eligible out-of-network mental-health expenses. It describes additional repayment obligations for other eligible members. These figures should not be presented as a guaranteed $10.35 million distribution to patients.
The provider-directory investigation
The attorney general’s office said a secret-shopper study found that 82 percent of surveyed Emblem behavioral-health providers listed by Carelon as accepting new patients were effectively unavailable. The problems included providers who could not be reached, were no longer practicing, were not accepting patients or were not actually in the network.
That percentage describes the providers surveyed in the investigation. It is not a measured finding about every Carelon clinician, every health plan or every Mohawk Valley practice. The office called the inaccurate listings a “ghost network.”
Investigators also said Carelon failed to respond adequately to members who could not find appointments. Those findings are attributed to the attorney general. The signed agreements have not yet been independently reviewed for this draft, including their admission or non-admission language, so this report does not characterize them as a court verdict or an admission by the company.
Potential reimbursement
According to the announcement, members forced to obtain out-of-network mental-health care because they could not get an in-network appointment may qualify for restitution for care received as early as January 1, 2020. An independent monitor will review claims and determine eligibility.
The office also said Carelon must repay eligible members who paid extra after a provider was incorrectly listed as in-network, with 12 percent interest. The announcement does not establish that every person who used an out-of-network provider will receive a payment.
Readers should retain bills, explanations of benefits, denial letters and records of attempts to find an appointment. They can ask their insurer whether Carelon administers their benefits and how settlement notices or claim instructions will be issued. A verified claims portal and filing deadline were not available in the source reviewed for this draft.
Changes to finding care
The announcement requires directory corrections within two business days and verification of provider information every 90 days. Carelon must confirm providers are accepting new patients before referring members and allow errors to be reported.
Providers who have not submitted claims in 90 days must be removed unless they confirm that they remain participating. Quarterly secret-shopper checks must count unreachable providers and unanswered calls, and results must be published, the office said.
Carelon must ensure urgent appointments within 24 hours and initial outpatient appointments within 10 business days. When a member reports being unable to obtain an in-network appointment and Carelon cannot find an appropriate provider within three business days, the member must be allowed out-of-network care at usual in-network costs, according to the announcement. Readers should obtain plan-specific confirmation rather than assume all outside services qualify automatically.
The addiction-treatment investigation
A separate investigation found at least 41 instances in which Carelon used unapproved medical-necessity criteria to deny substance-use treatment, the office said. Investigators also reviewed cases in which outside reviewers overturned denials and identified failures to consider patients’ full circumstances.
The office said Carelon must identify eligible members with out-of-pocket costs or unpaid bills following improper denials dating to January 1, 2020, and issue refunds within 180 days of that settlement’s effective date. This draft does not calculate a calendar deadline because the signed agreement’s effective date has not been verified.
Future reviews must use criteria approved by the state Office of Addiction Services and Supports and consider the full case file. The announcement says Carelon may not require a patient to fail at a lower level of care before approving a higher one, minimize withdrawal symptoms, or require proof of a serious-harm risk.
Oversight and source limitations
An independent monitor will review network accuracy, appointment access and other compliance measures and report to the attorney general every six months. These are required changes, not proof that access problems have already been resolved.
This draft is based on the attorney general’s November 10 official press release. The office links the provider-network agreement and the substance-use treatment agreement. Full agreement review, implementation dates, claims instructions and Carelon’s response remain reporting gaps. This item is held for editorial review.