APA FIRES ANOTHER SHOT AT MANAGED CARE
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January 11, 1999 12:00 AM

APA FIRES ANOTHER SHOT AT MANAGED CARE

Ann Saphir
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    The American Psychological Association is waging war on managed care, and its weapon of choice is the lawsuit.

    The latest suit pits the APA's Virginia affiliate, six clinical psychologists and two patients against the HMO owned by Blue Cross and Blue Shield of the National Capital Area, Washington. The suit, filed Dec. 10 in Superior Court of the District of Columbia, alleges that CapitalCare failed to deliver the mental health benefits it promised.

    The complaint was the second APA-backed suit filed against a health plan last year.

    Russ Newman, APA's executive director for professional practice, said the suits are "test cases where we can bring to light in the courts what the practices are in the industry."

    HMOs have advertised falsely, made clinical decisions and sanctioned providers who deliver "too much" care, among other practices, he said.

    The latest suit alleges that CapitalCare falsely advertised the number of psychologists in its network. That number had shrunk dramatically because the plan had decided to cut reimbursement rates, according to the lawsuit.

    A spokeswoman for the Blues said company policy precluded comment on pending litigation.

    The suits are part of a larger APA agenda, which is to counter the assumption "that market forces can fix all problems in a healthcare system," Newman said.

    Newman argues that mental healthcare is unsuited to the utilization guidelines typical in managed care. Patients' responses to treatment vary more in mental healthcare, he said.

    To pay for the lawsuits, the association has tapped its psychology defense fund and raised its dues.

    The APA fired its first shot in May 1996, when its New Jersey affiliate and seven psychologists took MCC Behavioral Care to court. They alleged that the Parsippany, N.J.-based company fired or threatened to fire providers who requested a number of sessions that the plan may have considered excessive even though the number was within plan limits.

    MCC spokesman Howard Dresher said the company denies that the termination of about 50 providers from the network was anything but "an economic decision." The case is still in the evidence-gathering phase.

    A third suit, which the California Psychological Association filed in September 1998 in Los Angeles Superior Court, charges Aetna U.S. Healthcare with false advertising. Aetna moved the case to federal court and requested dismissal on the basis of its exemption under the Employment Retirement Income Security Act. ERISA exempts self-insured companies from state laws governing the business of health insurance. A federal judge will rule on jurisdiction on Jan. 13.

    The APA is considering filing another lawsuit in Tennessee related to an HMO that participates in the state Medicaid program. It's also looking for a test case for mental health confidentiality issues, Newman said.

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