Families Sue UBH for Failing to Cover Medically Necessary Mental Health Treatments

Last month, I had the honor to watch a class action lawsuit in US District Court, Northern District of CA, where a group of very committed United Behavioral Health (UBH) members sued UBH for failing to use adequate standards in determining necessity of Residential and Intensive Outpatient Mental Health Therapies (Wit vs UBH and Alexander Vs UBH).  Plaintiffs, represented by Zuckerman Spaeder and Psych-Appeal, argued that guidelines developed by UBH overemphasize the “why now” factors, (the acute issues that led to an immediate crisis), rather than address the chronic underlying co-morbid mental health issues.

Dr Mark Fishman, who helped develop and revise the American Society for Addiction Medicine (ASAM) criteria, national standards which guide treatment placement for substance abuse, provided expert testimony on behalf of the plaintiffs.  “UBH’s criteria have a narrow focus, as they require that members be at an imminent risk of danger or harm to self and others as requirements for both admission and continued stay.  Once stabilization has occurred, UBH’s guidelines emphasize discharge.  Safety is important, but not to the exclusion of other factors, including overall ability to function, efficacy of treatment, risk of relapse, willingness to participate in lower levels of care, recovery environment (home and community may be contributing to the problems), as well as treating the underlying co-morbid mental health conditions.”

Overall, Dr Fishman opined that UBH’s criteria form an atmosphere of restriction that limits access to treatment.  “We need multiple pathways to access mental health treatment.  Chronic factors, not just the precipitating event, must be considered, as the cumulative severity of mental health problems greatly impact the ability to function.”

Severe mental health crises are typically handled in mental health hospitals.  Residential treatment includes a broad spectrum of treatment levels, from sub-acute, medically managed settings with 24 hour nursing, to low-intensity residential programs which emphasize psycho-social interventions with community integration.  Typically, lower intensity facilities have lower per diem costs, though patients may stay longer.  The entire range is part of the mental health system of care and most mental health advocates agree that all levels should be covered by insurance.

Over 60,000 plaintiffs may be impacted by this class action, which includes UBH  members from 2011 through June of 2017 who were denied mental health treatment based on UBH’s guidelines.  Descriptions of who is eligible for the class can be found here for residential treatment, and here for outpatient/intensive outpatient.      The cases are currently under consideration by US Magistrate Judge Joseph Spero.   More details about the cases can be found here.

A similar class action against Magellan/Blue Shield of CA was recently filed, certified, and will be moving forward.  

Plaintiffs with Attorneys from Psych-Appeal and Zuckerman-Spaeder

   

Back in Treatment, --This Time for a Visit

By Debra Nelson

I look out into the audience of 40 people and see a woman quietly crying.  She has a box of tissues in her hands.  Other people look attentive, bored or exhausted. The teenagers look especially annoyed to be sitting in hard-backed chairs in a school gym at 8:30 am.

My husband and I are sitting on a raised dais between two potted plants at Intermountain Children’s Home in Helena, MT answering questions about how we took care of ourselves during the 18 months our son, Asher, was at this residential treatment center (RTC) for emotionally disturbed children.

I try and be hopeful and funny with my remarks.  My husband mentions things that I don’t remember about Asher’s unsafe and provocative behavior.  My memory from the beginning of his stay at Intermountain isn’t very good.

Parents ask us questions about how we prepared for Asher’s return home. One parent says how scared she is to have her child come home.  She doesn’t feel ready. I tell her that I felt the same way.

We are back in treatment – returning to the place that provided so much support, therapy and understanding to our entire family.  Asher has been invited to give a prepared address to the kids about his experience at Intermountain and what he has learned in the year he has been back home.  My husband and I decided to both attend, and my 82-year-old mom is with us as well to enjoy this meaningful event.

Asher delivers the speech beautifully, describing how much he hated coming to Intermountain, how much he struggled, and ultimately how much he learned from the wonderful, firm, and caring staff about his own challenges and strengths.  He says that he now has a much better life.

An RTC for emotionally troubled kids is a strange place.  It is structured and very staff-heavy.  There are cryptic phrases that everyone uses, clear consequences, and things run on tight schedules.  There is lots of therapy-- group, individual and in the milieu.  Kids talk about “their treatment” and their goals they are working on.  They also talk about what they need to do to go home.

An RTC is also the most normal place. There is no “secret sauce”. There is predictability, focus on relationships between children and adults, and staff who are highly trained to deliver consistent treatment to each child.

Asher spends most of his Helena visit spending time with the staff.  We meet a few staff for special meals or hikes in the hills of Helena.  He is eager to tell them how well he is doing. Some of what he says is stretching the truth a bit -- “school is really good!” -- but he shares how life at home is much more structured, the names of his new therapists, details about his after-school activities, and how he feels since leaving Intermountain.  He also tells the staff how much he misses them.

We round out our trip with a few favorites:  ice cream at the local shop, a walk around a lake, dinner at the Mediterranean Café.  My husband and I join some of the staff for a beer at a local bar.  We laugh and share memories.  We hear about the good and difficult parts of their lives.  We fly home and I add the printed program from the day at Intermountain and a copy of Asher’s speech to his memory book.

When I talk about “treatment” with Asher these days, he reminds me that he’s not in treatment any more.  Rather, he’s out of treatment but still working on his goals.  I, however, still feel that I am in treatment.  There are so many things to remember and integrate from our experience at Intermountain, and I am still working on them every day.

I’m not sure if we will go back to Intermountain any time soon. It felt so important to return, to have a final chapter in our story. I think about the little boy who moved into our son’s room when he departed, and try to imagine how he and his family are doing and what their story will be after his discharge home. I hope that they too will have a happy chapter.  I also hope that they will share our gratitude that Intermountain was there to provide the treatment that we needed.

Asher at his visit to InterMountain Children’s Home, after speaking to a group of families about his experiences.

Debra Nelson joined the Mental Health and Autism Insurance Project last year and has been assisting families in writing appeals and obtaining insurance funding for mental health and autism treatments.  She has helped our organization broaden its focus from working solely with the autism community to also working daily with those with mental health conditions. Her experiences with RTC has helped inform and guide us in our work. 

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California Department of Managed Health Care (DMHC) has taken enforcement action including a $5 million fine against Blue Cross of California (Anthem Blue Cross)

Anthem Blue Cross has demonstrated a pattern and practice of failing to identify, timely process and resolve enrollees’ grievances. This along with failing to provide the DMHC with timely or complete information has landed Anthem Blue Cross in some legal problems. "The plan must correct the deficiencies in their grievance and appeals system and comply with the law" noted DMHC Director Shelley Rouillard.

The enforcement action is the result of deficiencies of service identified in DMHC surveys and via the DMHC help center during a period from 2013 to 2016. Some of these reported grievances came through MHAIP.  This fine against Anthem Blue Cross is $5 million, but in addition the DMHC has fined $11.66 million for grievance system violations since 2002.

To read more detailed information on this story CLICK HERE  For additional information on this enforcement action  CLICK HERE 

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CONTRIBUTE TO MHAIP's END OF YEAR CAMPAIGN

Once again, the end of the year is upon us.  We at the Mental Health and Autism Insurance Project rely on your continued support to provide the following programs to our families:
1)     We provide advice to low-income families on how to appeal denials for autism and mental health interventions.
2)     We monitor legislation and inform policy makers on the needs of our special communities.
3)     We work closely with regulators, bringing systemic gaps and problems to their attention, so that they can enforce the law when health plans fail to follow it.
4)      We educate providers, facilities, and families on how to work with insurance, so that YOU can get your services covered.
Or donate directly through our website.
OTHER WAYS TO SUPPORT MHAIP:  
Donate while you shop this holiday season
(Listed as Autism Health Insurance Project)
PAY PAL GIVING FUND  
SMILE.AMAZON.COM
EBAY, as either a buyer or seller
Through Employee Giving:
We are a recognized cause through the corporate employer-matching philanthropic site  Benevity (as Mental Health and Autism Insurance Project).
We so appreciate your support!
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Cases We Have Won (This is a partial list of recent victories).  MHAIP obtained coverage for 50 days of care at a residential treatment center for a young man from New York. MHAIP’s appeal on his behalf also prompted his health plan to drop a restrictive facility accreditation requirement that illegally cut access to mental health care.

MHAIP helped the family of a 22-year-old man with depression and substance addictions obtain coverage for 50 days of residential mental health treatment. Beacon Health Options had refused to pay for his care because the treatment facility was not accredited by a particular organization – even though the facility was properly licensed as a residential treatment center and had earned accreditation from the Outdoor Behavioral Healthcare Council. MHAIP helped his parents file a complaint with the New York Attorney General explaining that the plan’s unduly restrictive accreditation requirement violated a federal law requiring plans to pay for mental health services in parity with their coverage of medical treatments. After the Attorney General investigated the matter, the insurance plan agreed to pay for young man’s treatment and to remove the superfluous accreditation requirement from its insurance plans for other members.

MHAIP helped a 17-year-old girl in Illinois receive coverage for nearly one year of residential mental health treatment.

  

MHAIP represented a 17-year-old girl who received long-term care at a residential treatment center after suffering from depression, anxiety, PTSD, and substance addictions that led to many dangerous behaviors. After a single week of residential treatment, Blue Cross Blue Shield had denied coverage for the rest of her care. The plan claimed it was not “medically necessary” because the teenager was not in immediate danger of harming herself. MHAIP filed an appeal with the Illinois Department of Insurance, arguing the plan had applied the wrong standard in determining whether her treatment was necessary. MHAIP explained that the relevant question was not whether this troubled teenager faced an imminent risk of suicide, but instead whether she needed sustained residential treatment in order to stabilize her serious mental health conditions. An independent review organization agreed with MHAIP, stating that the teenager required the continued structure of a residential program in order to learn and practice “improved coping skills, relapse prevention techniques, . . . life skills, . . . improved insight and motivation, [and] family intensive work.” The Illinois Department of Insurance directed Blue Cross Blue Shield to pay for nearly one year (50 weeks) of her residential treatment.

MHAIP helped three young children with autism obtain multidisciplinary treatment at an Intensive Outpatient Program.

MHAIP represented three children with autism under the age of four who had been denied care at a short-term intensive outpatient treatment program that provides multidisciplinary interventions for children with autism and co-occurring conditions such as anxiety. The children’s health insurance plan, Anthem Blue Cross, had refused to authorize the treatment, even though the IOP center was in-network with Anthem. In each case, the plan claimed the toddler needed only ABA treatment, even though each child either faced a long wait time before he could begin an ABA program, or had been receiving ABA but was continuing to struggle with worsening symptoms and dangerous behaviors. MHAIP filed expedited appeals on behalf of each child with the California Department of Managed Health Care. In each case, the DMHC ordered the plan to authorize the child’s immediate IOP treatment.

MHAIP recovered over 25K for a Wilderness Program

MHAIP recovered over $25,000 for a 54 day stay in a Wilderness program from Blue Cross Blue Shield after requesting a medical necessity retro-authorization. The 18 year-old from Kansas had come from a lower level residential treatment facility and had suffered from depression, anxiety, and severe anger management issues.

MHAIP won 65 days of RTC treatment for 16 year-old with eating disorders

MHAIP assisted the family of a 16 year-old CA girl with eating disorders, depression, and suicidal ideation in obtaining 65 days of coverage at a residential facility in Utah. The family recovered over $18,000 from Blue Shield of CA, which is over 75% of the costs for the period. The family contacted us before their daughter entered the facility. When this happens, we are able to obtain authorizations in real time and have a much higher success rate.

MHAIP has won 61 days (and counting) of RTC treatment for a 16 year-old teen.

We are assisting the family of a CA boy with OCD and major depression in getting coverage for his stay at a residential treatment facility. This family also came to us prior to entering the facility. We have been calling in weekly to Com Psych and obtaining ongoing authorizations.

MHAIP helped a client negotiate a paid settlement with his employer for ABA services for his son.

 

When our client’s employer changed to a new insurance plan, the plan refused to cover ABA therapy services for his 6-year-old son with autism that had previously been covered at 100%. Their website and customer service department also misrepresented the availability of in-network ABA services. MHAIP assisted our client in presenting the erroneous and misleading information to his company and educating them on the importance of robust autism services. As a result, the employer offered the father a cash settlement for out-of-pocket expenses incurred for the ABA services and stated that it would be including autism spectrum disorder coverage in all of their plans in 2018.

MHAIP recovered over 26K in therapy services for a girl’s stay at a residential treatment center

MHAIP assisted the family of a 17-year-old girl with anxiety, social anxiety disorder and major depressive disorder recover full payment for individual, group and family therapy sessions during her 13-month stay at a residential treatment center.

MHAIP helped a five-year-old boy with autism receive in-school ABA services

MHAIP won a case that compelled a Medi-Cal insurance company to provide in-school ABA services for a five-year-old boy with autism. The insurance company insisted that it could not provide ABA services in a school setting, refused to issue a formal denial for services to the ABA provider, and then declared the ABA services not medically necessary. MHAIP brought the case to the California Department of Managed Health Care, which agreed that ABA services were both medically necessary and should be provided in the school setting.

MHAIP helped get partial payment for out-of-network autism therapy providers.

 

Chalk this one up to “you never know what’s going to happen, so you might as well ask!” MHAIP represented a client who utilized out-of-network providers for her 5-year-old son with autism. In a five-hour-long phone call, MHAIP spoke with insurance company representatives requesting full payment for these out-of-network providers since in-network providers had little availability. A representative agreed to make a “one-time exception” and paid $16K for the full billed amount of six months of services speech, OT and behavioral health therapy.

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Wishing you a happy, healthy and prosperous holiday season and new year!!
Sincerely,
Karen Fessel
Executive Director & Founder
Mental Health & Autism Insurance Project