They are often surprised and dismayed when they learn that the actions of a care manager can result in the delivery of benefits different from those advertised or for which they contracted. Health plans that do not make advance disclosure of exclusions imposed by the contracted behavioral care carveout may be in breach of insurance regulations in some jurisdictions. The withholding of benefits promised by the plan may be construed as a breach of its contract with the insured. Enforcement can occur only if violations are made known. Available mechanisms for doing so include media stories, court action or the filing of formal complaints with state agencies that regulate insurance companies and health plans.
Regulatory actions are far less expensive, faster and easier than litigation.
Compared with litigation or legislation, regulatory actions are certainly more feasible for individual psychiatrists and patients. In legislative arenas, it often seems that overwhelming public sentiment and the needs of patients have less impact than does the dollar. Huge corporate lobbying budgets and the prospect of generous campaign contributions from business and the insurance industry can be very persuasive. In state administrative agencies, political fund-raising is less likely to be an influence, and the impulse to do work that benefits the public welfare may be a stronger ethic. In the quest for managed care reform and true parity, we may do far better to concentrate more financial and lobbying resources in these regulatory settings.