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Complete 12 Week Stay in Outdoor Mental Health Program
MHAIP recovered over $45,000 in payments for a twelve week stay in a hybrid Wilderness program for a 16 year old CA girl with depression, anxiety and eating disorders. We submitted claims to the plan, Blue Shield of CA. They repeatedly lost documents and told us incorrect information on the phone, which we documented with tracking numbers. We filed a formal grievance, which they failed to resolve or respond to. Later, we filed a formal complaint with the CA Department of Managed Health Care (DMHC). With the involvement of the DMHC, the plan ended up making an exception, and paid all claims in full.
Recovered Over $325,000 for 15 families in one RTC
We recovered over $325,000 for 15 families in one residential facility over a six month period through the utilization review process. When we work with facilities, it is often more efficient than working with one family at a time, as we get to know the therapists, and they quickly learn the information we need to successfully work with the health plans. We also can reach out to families as soon as their children enter the program, which allows
First Six Months of One Year RTC Stay Overturned
MHAIP successfully recovered out-of-network benefits for six months from Premera Blue Cross for long-term residential treatment of a Colorado woman, who suffers from depression and eating disorders. We are currently working on recovering the second six-month period of her stay, despite the period being considered outside of “timely filing.” Because the client was legally incapacitated during her stay, the timely filing clock starts from the time discharge. It is looking good that this second period will be covered as well.
ABA Case Overturned by DMHC Legal
MHAIP appealed the denial of behavior therapy of a four year old Los Angeles boy with autism. Services were denied by Anthem after they were initially approved, because the provider was in-network with Anthem Medi-Cal, not Anthem commercial. We appealed, the denial was upheld by the plan. We filed a complaint with the CA state Department of Managed Health Care, and they ordered that the case be overturned, because Anthem violated CA law AB 1324, which requires that plans may not rescind payment after services have been authorized and rendered.
Overturn in External Review for RTC
We won an external medical necessity review to get mental health and substance abuse residential treatment covered for a young man from Texas. Despite the case being denied twice by the Blue Cross Blue Shield of Texas, we were able to document that the young man’s behaviors at the treatment center showed that he met the mental health residential treatment criteria for continued stay. The external review organization reversed the insurance company's decision, compelling the insurance company to cover his stay.
Recovered over 41K for 89 day stay in Outdoor Mental Health Program
MHAIP recently recovered over $41,000 for the family of a Kansas young man with anxiety and depression, who was treated in an outdoor mental health program for 89 days. Blue Cross Blue Shield repeatedly lost documents and failed to process claims. We requested that the employer step in and provide assistance, and after nearly a year of conversation, the plan paid.
Employer Intervened and Overturned United Denial for RTC
MHAIP appealed the denial of continued care for a 17 year-old youth with mood disorder, self-harm and severe substance abuse. He had been in residential treatment for two months, but was continuing to have multiple incidents and had not stabilized. After two months, care was dropped down to the partial hospital level of care. A few weeks later, United denied at the partial hospital level, as well. We appealed to both United and the employer, reviewing the client’s behaviors and arguing that he did in fact meet United’s criteria for continued stay at the residential level of care. The employer intervened and ordered United to cover an additional two months at the residential level of treatment.
Overturn from Beacon for Denying for Conflicting Reasons
MHAIP received an initial ten days of coverage for residential stay for an 18 year old man with severe anxiety and depression. After ten days, Beacon told that us that the client needed a higher level of treatment and future care would be denied. We requested reconsideration and a second Beacon psychiatrist determined that the client’s condition was not severe enough to justify further treatment, for the same timer period. We submitted an expedited appeal, alleging that Beacon was shopping for a denial. The appeal was partially overturned, and we will be submitting an additional appeal for additional days of coverage.
Federal Government ordered Overturn after Plan Retroactively Changed Terms of Coverage
MHAIP helped a six-year-old CA boy with autism receive coverage for his speech and occupational therapies for 17 months. His health insurance had been obtained through his mother's employer, a school district. When his insurance company, POMCO, retroactively changed his health plan to exclude autism services, MHAIP filed a successful appeal with the federal government, who ordered that the plan pay retroactively.
Assisted Parent in Writing Successful Appeal for Wilderness
We helped an Arizona-based parent of a 14 year old girl with severe depression, in writing her own appeal to BCBS for a denial for her daughter’s participation in a 49 day wilderness program. She successfully recovered out of network benefits for her daughter’s stay, which paid 50% of the total cost of the program.
State Regulator Ordered Plan to Cover Previously Approved RTC stay
MHAIP assisted the parents of a 15-year-old boy from New Jersey with Bipolar Disorder. His insurance plan, United, had refused to pay for his continued residential treatment on the grounds his care no longer was medically necessary, after having previously approved the treatment in utilization review. We filed an appeal with the New Jersey state regulators, and the insurance plan then agreed to pay for an additional six weeks of his residential treatment.
Complete Hybrid Wilderness Program Covered through Utilization Review
MHAIP won the complete 82 day stay from Cigna through ongoing utilization review for an 18 year old CA woman with anxiety and depression in a Hybrid Wilderness program.
We helped the family of a 16 year old boy recover over $40,000 and ongoing in claims from Blue Shield of CA, for six months in an RTC program.