Feature

In separate actions, two APA members have filed lawsuits against two of the country's largest managed-care companies. A claim against Aetna U.S. Healthcare focuses on patient confidentiality; the second suit charges that Magellan is usurping practitioners' authority to provide care and disregarding the patients' welfare.

In the suit against Aetna U.S. Healthcare, New Jersey psychologist Russell Holstein, PhD, claims he was wrongly terminated from the managed-care network because he refused to violate the state's Peer Review Act--a law stipulating that psychologists dealing with third-party payors must keep the details of their patient's treatment and condition confidential even if the patient releases the information.

Holstein says Human Affairs International (HAI) insisted on patient treatment information even though its own contract required him to follow New Jersey law. He filed his suit against HAI and Aetna U.S. Healthcare, HAI's parent company at the time, as well as Magellan managed care, the current parent company.

"Confidentiality is one of the most effective ingredients that makes psychological treatment work," says Holstein. "If we give it away, we make ourselves ineffective and disempowered."

Originally HAI approved eight psychotherapy sessions for Holstein's patient. But, according to the suit, when Holstein requested additional sessions, HAI asked for information including whether the patient was a threat to him or herself or others; a medical evaluation of the patient's prescribed medication; a detailed list of symptoms and medications; details regarding the use and dependency on drugs and alcohol; a detailed clinical synopsis and treatment goals; the progress toward those goals; treatment criteria and community resources.

Holstein refused to provide this information, citing the state's Peer Review Act, which allows psychologists to release only the patient's case identification number and administrative information; whether the patient is being treated on an inpatient or outpatient basis; the duration and frequency of treatment; the diagnosis and prognosis; and the level of function and distress, whether mild, moderate, severe or extreme.

In the lawsuit against Magellan, Florida psychologist Richard Brown, PhD, is charging that the company arbitrarily terminated his patients' mental health services in retaliation for his efforts to enforce an agreement with the company.

Brown's complaint expands on a lawsuit he filed in April, charging Magellan with failure to reimburse him for preapproved mental health services. He alleges that, through arbitrary, blanket terminations of care, the managed-care company inappropriately interfered with the relationships he had developed with his patients. He charged that Magellan repeatedly ignored his warnings that termination of care would be detrimental to his patients' well-being. The lawsuit further charges Magellan with fraudulent misrepresentation and breach of contract for failing to permit Brown to exercise his professional judgment in providing services and for refusing to pay for authorized services.

APA's Practice Directorate worked with Brown and his attorney to prepare the amended complaint targeting Magellan's alleged retaliatory actions against the psychologist.

"What started as a simple contract dispute," says Russ Newman, PhD, JD, of the Practice Directorate, "seems to have grown to become another instance in which a managed-care company retaliates against a health-care professional who attempts to enforce his rights or the rights of his patients."

Newman says the issue here is managed-care decision-making without regard to patient well-being.

Brown's suit is one of four lawsuits brought with the support of APA to challenge managed-care practices that endanger the health of patients and usurp the clinical decision-making of qualified health professionals.