Months after Kaiser Permanente reached a sweeping agreement with state regulators to improve its mental health services, the healthcare giant is facing allegations that patients could be improperly losing such care.

The National Union of Healthcare Workers, which represents thousands of Kaiser mental health professionals, complained earlier this year to state regulators that Kaiser appeared to be inappropriately handing off decisions about whether therapy is still medically necessary.

The union alleged that Rula Health, a contracted network of therapists that Kaiser uses to provide virtual care to its members, had been directed by Kaiser to use “illegal criteria” to make those decisions during regular reviews.

California requires such decisions about mental health care to be based on criteria developed by professional groups, but the union said there was no evidence that was happening. Instead, the union complained that documents indicated Rula was relying on questions answered by Kaiser patients about their own symptoms.

The risk is that patients “have a psychological disorder that requires additional treatment and Kaiser is unfairly and improperly terminating their access to care,” said Fred Seavey, a researcher for the union.

The union also alleged that regularly requiring such “clinical care reviews” violated laws barring insurers from putting up barriers to mental healthcare that don’t exist for other health conditions. Kaiser does not subject other outpatient care to such reviews, “let alone at such frequencies,” the union said in its complaint.

The union called on the California Department of Managed Health Care to order Kaiser to immediately halt that review process and notify any Kaiser patients whose treatment was “illegally terminated” by Rula.

Kaiser said in a statement that it does not set limits on the number of therapy sessions, and that “the level of therapy needed and the frequency and number of sessions for any patient is a decision made by our mental health care providers in consultation with patients and as appropriate based on the patient’s clinical needs.”

It added that “the self-assessment tools do not determine whether treatment remains medically necessary. … Patient self-assessment tools may be used as one aspect of gathering information from the patient but are never the only factor.”

A Department of Managed Health Care spokesperson said its enforcement office was looking into the issues raised by the union under its recent settlement with Kaiser. That agreement, reached last fall, required Kaiser to pay a $50-million penalty and invest $150 million over five years into improving its mental healthcare.

The state agency said it had found shortcomings at Kaiser related to failures to provide timely appointments, insufficient oversight of medical groups in determining “appropriate care,” and inadequate handling of patient grievances, among other issues.

Among the problems that DMHC noted: Medical records for patients did not show the use of legally required guidelines for making decisions about mental health treatment. Patient records instead showed “self-assessment scores” from questionnaires, according to the settlement agrement.

Kaiser Permanente chief executive Greg A. Adams said last year that the organization had seen demand for mental healthcare surge amid the pandemic, which collided with an “ongoing shortage of qualified mental health professionals, clinician burnout and turnover,” as well as a 10-day strike by mental health clinicians.

In a recent statement, Kaiser said it was “in the process of implementing transformational changes contemplated by the settlement agreement,” including a “dramatic increase in the number of providers available to see our members — both newly-hired therapists and contracted therapists.”

A Rula spokesperson said in a statement that its therapists, “in collaboration with their patients, make all clinical decisions around the course of care.”

In Chino, Jaklynn Fuentes-Soto said she was told by her therapist earlier this year that her sessions with the Rula provider would soon stop, even though “my therapist thought that I should continue treatment.” The 25-year-old said that if she wanted to keep seeing the therapist, she would have to pay out of pocket.

As a student working part time, “I don’t think that financially I’m able to.”

Fuentes-Soto said she has been diagnosed with major depressive disorder and other mental health conditions. She said she had been regularly seeing her therapist after one episode led her mother to take her to the emergency room.

“If I’m not having the help that I need for my mental health,” she said, “it has me regress to a very dark place.”