Finding the appropriate mental or behavioral health clinician for children and adolescents in this is area is very hard. There are laws in Massachusetts that are intended to make finding appropriate services easier. However, most people do not know about the laws or how to use them to get coverage for services.

If the clinician most suited for you is not in your network be aware that the Managed Care Reform Act requires most Massachusetts managed care and insurance companies to provide adequate access to "all mandated provider types" (e.g., psychiatrists or psychologists); a full range of mandated services including specific treatment modalities appropriate for all ages of patients and all types of covered mental conditions; and there are sufficient number of providers available in the network so that no patient must wait a medically inappropriate amount of time to receive care of acute conditions. If you believe your network is not complying with the law you may insist that they provide a single case agreement for the doctor you believe can meet your needs.

Typically you must be prepared to convince them that you tried and failed to find a clinician within your area, who has the expertise and training you need, and is available in your network before they will give an out of network authorization. They may request the tax identification for our practice in order to provide the authorization. Our tax id is 04-322-8346.

If you get an out of network authorization make sure it is for the doctor’s full rates. Networks often approve authorizations at their discounted rates which may be 50% less than the doctor’s charge. Our practice does not accept the discounted rates. Please have them fax the agreement to 781-551-3396.

If they refuse you may want to inform them that you believe they may be breaching their contract with you.

You may wish to request to speak to a supervisor. Let them know you if you plan to notify the Bureau of Managed Care and your employer’s human resources department.

If they refuse to provide an out of network authorization you may file a complaint with the Bureau of Managed Care at 617-521-7372, by fax at 617-521-7773, or by email at bmc.mailbox@state.ma.us. More information about the law is also available at their website http://www.mass.gov/doi/Managed_Care/managed_care_home.html.

Inform them that you are unable to find appropriate care within the network and unable to obtain an out of network authorization and request their help. The employer is the "customer" who the insurers want to please. When they contact the sales department at the managed care company they are usually successful at obtaining authorization.

Contact Susan Fendell at the state’s Mental Health Legal Advisors. You may contact her by email at sfendell@email.mhl.state.ma.us. She has been very successful in convincing local HMOs to provide coverage for out of network doctors when they are not available in the network. You can call her at 617-338-2345.

OPTION 5: Request Help from the Health Law Advocates. HLA represents low income Massachusetts residents denied access to health care. To be eligible for services family income must be less than 300% of the Federal Poverty Line, which is approximately $60,000 a year for a family of four.  Call 617-338-5241.

OPTION 6. File a complaint with the Massachusetts Division of Insurances
    http://www.mass.gov/Eoca/docs//doi/Consumer/css_complaint_form.PDF

OPTION 7: Let the Lawmakers Know That the Law is Not Being Followed and Request Action          

Representative Ruth Balser, Ph.D., Co-Chair Joint Committee on Mental Health and Substance Abuse
State House, Room 33
Boston, MA 02133
Telephone: 617-722-2060
Facsimile: 617-722-2850
E-Mail: Rep.RuthBalser@hou.state.ma.us

Senator Steven Tolman
State House
Room 511-B
Boston, MA 02133
Telephone: (617) 722-1280 Fax: (617) 722-1069 State House E-Mail Address: Steven.Tolman@state.ma.us

Director, Office of Patient Protection via Facsimile 617-624-5046

Julie M. Bowler, Commissioner of the Massachusetts Division of Insurance,
via Facsimile 617-973-8798 

Contact your State Senator and Representative
http://www.state.ma.us/legis/citytown.htm