MPA Passes Law to Curb Lack of Transparency in "Medical Necessity Criteria Sets"

Dr. Karen Postal and her colleagues at the Massachusetts Psychological Association (MPA) successfully passed a law to curb the lack of transparency in "medical necessity criteria sets" within Massachusetts. Dr. Postal's description of the victory follows:
We are very pleased to announce a major win for neuropsychologists and patients in the commonwealth. As many of you know, MNS and MPA have been jointly engaged in advocacy to address the lack of transparency in "medical necessity criteria sets" (such as McKesson criteria) adopted to manage the neuropsychology testing benefits by large insurance companies in the state. Many criteria sets are now purchased from for-profit corporations, and they have declared that they are licensed, proprietary "trade secrets" therefore not open to scrutiny as to their scientific validity. While we applaud the concept of evidence based medicine, secret, proprietary medical necessity criteria sets pose a serious consumer protection issue. If it's not transparent, we have no idea if it's good science.

In the past, neuropsychologists had no recourse to contest the validity of the science behind these criteria sets that limited access to neuropsychological assessment services. Each patient's denial of authorization had to be individually appealed with the Office of Patient Protection. Neither vulnerable patients, nor overworked practitioners had the resources to mount an appeal with every denial. The result has been restriction of access to care for some of the most vulnerable patients in the commonwealth.

As a direct result of MNS and MPA advocacy, and with the assistance of attorneys in APA Practice Directorate's Office of Legal & Regulatory Affairs, our "Transparency Bill" language has been adopted within the new healthcare bill signed by Governor Patrick. The language allows, for the first time, entire medical necessity criteria sets to be reviewed by the Office of Patient Protection.

This is a game changer. Our organizations will partner with the Inter-Organizational Practice Committee (IOPC), a super committee of AACN, NAN, D40, and ABN to launch a state of the art review and challenge to parts of the criteria sets that don't fit with established research.

We would like to thank the APA Practice Directorate, the Massachusetts Psychological Association, and a group of highly dedicated, tireless advocates for their effective work on this issue. Roger Cohen, Michelle Imber, Elena Eisman, Mary Coakley-Welch, Claudia Rutherford, Joel Rosenbaum, Shirley Ann Higuchi and Alan Nessman (Legal & Regulatory Affairs, APA Practice Directorate), as well as Ben Fiero and Patricia Lynch (Lobbyists for MPA). You rock!

Karen Spangenberg Postal, PhD, ABPP (CN)
Telephone: (978) 475-2025