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MHAIP Case Wins
New York State Attorney General’s Office Overturns RTC Denial
A student at a university in the state of New York, suffering from Major Depressive Disorder was treated for 3 months at a residential treatment center in Texas. The family submitted claims which were denied. MHAIP appealed the claim denials and received an adverse determination from the insurer, CD PHP. The appeal denial included outrageous language in the decision, writing that the Plan’s coverage did not include ”…programs that offer resort-style amenities and are located in resort-style geographic locations such as mountain or country settings.” This apparently referred to the fact that the facility is located in a rural setting in Texas, and also offers equine therapy, as many programs do. MHAIP filed a complaint on the family’s behalf with the New York State Attorney General’s Office saying we believed the denial was a violation of federal MHPAEA law. The NY AG had the case reviewed by their Parity expert and the NY AG’s office compelled CD PHP to overturn the denial and pay the claims. The NY AG's office has been active in enforcement of the Parity Act for NY state regulated plans. The family was reimbursed for 3 months of RTC treatment at the out of network level for a total of $24,425.
"A little over a year ago I was notified that my daughter's health insurer had denied a substantial claim. I was surprised and shocked. The health facility we were dealing with recommended that we work with Mental Health and Autism Insurance Project. I had never used an advocate before and did not know what to expect. My first conversation with Karen Fessel was so comforting. Her mission is remarkable. She understood the issues immediately and assigned me to work with Marcy Smith. Marcy was so clear and logical. After getting a second denial, Marcy chose to go to the NY Attorney General. She described the situation and won! The Insurer was forced to pay the claim. Both my daughter and I are so grateful to you for helping us with this critical situation. I would recommend Mental Health and Autism Insurance project to anyone facing an insurance denial."
External Review Overturns Residential Denial for 33 Days of Care
Anthem covered 13 days at the residential level for a Texas teen at an in-network facility and then denied the remaining 33 days of residential care. The adolescent was recently diagnosed with Autism Spectrum Disorder, Level 1, in addition to Depressive Disorder, Anxiety Disorder and ADHD. Parents had submitted 2 levels of appeals and been denied. MHAIP filed an External Review request outlining how the patient indeed met the criteria for residential care. The External Review ruled to overturn Anthem's denial and compelled Anthem to cover the 33 days at the residential level.
Pre and Ongoing Authorizations by MHAIP
The surest way to get approvals for residential treatment is to have the facility (or us, if the facility does not do it) call the plan on day one, provide clinical information, and give the health plan an opportunity to determine if the client (and the facility) meet medical necessity standards. We do this as needed when clients reach out to us early in the process and are often successful. We also encourage parents to explore the plan network. If there is not an appropriate facility in the plan, we can often get approved at the in-network level, which pays more.
MHAIP has secured seven months to date (and ongoing) of residential level mental health treatment for a Maryland teen with moderate autism and anxiety from Care First of MD at an out of network Utah facility that specializes in treating teens with ASD.
MHAIP is handling authorizations for a 13 year old male with ASD and other mental health diagnoses at the same out-of-network facility mentioned above. MHAIP demonstrated that the Plan had an insufficient network for this patient's needs and requested coverage at the in-network rate. The initial authorization as for 25 days at the RTC level. The insurer, BlueCross Blue Shield of North Carolina, then stepped down coverage to the PHP (Partial Hospitalization) level of care for this youth with a Level 2 ASD diagnosis accompanied by Anxiety Disorder and ADHD, for 50 days thus far.
We have also helped an Oregon trans youth who has an ASD diagnosis along with ADHD and Anxiety Disorder. MHAIP has worked to get coverage at the in-network rate at this same facility (a "Single Case Agreement" or SCA) for 58 days at the residential level of care. Aetna then stepped coverage down to the IOP (Intensive Outpatient) level and has thus far covered 90 days.
MHAIP continues to manage ongoing reviews for all cases. The important thing is to reach out early, explore the network and request services when you start treatment.
Urgent Placement Secured After Kaiser Denial
MHAIP helped the parents of an 11 year old boy from Northern CA with autism and chronic pain obtain a 90 day placement at a residential treatment facility from Kaiser. After going to the emergency room, the family was told that the facilities that were available would not be appropriate, due to his autism. They sent him home, though he remained in a highly agitated stated. MHAIP appealed initially to Kaiser on an expedited basis, as according to CA state law, the plan must find a suitable placement outside of the plan if none are available within the plan. Kaiser denied, and we sent the case to expedited external review, where it was overturned and the child was placed in an appropriate facility.
Full Coverage for Out-of-Network Residential Stay Won on Appeal
The parents of a 13 year-old non-binary teen from San Francisco requested mental health stabilization and assessment from a mental health hospital in Utah. The client had been in residential treatment but had been repeatedly self-harming. Because they were in a HealthNet/MHN HMO plan, the parents requested a single case agreement with the mental health hospital. After we appealed, Healthnet/MHN told them that they had appropriate programs, and named two residential treatment centers. The parent called both centers, and was told that their child was too acute. When she called the plan back, they told her to file an appeal. MHAIP got involved and filed an expedited appeal, informing the plan that they are legally obliged to find an appropriate program for their member. Healthnet/MHN overturned the case and ultimately approved and paid for the entire stay. The family was reimbursed at the plan's in-network rate of 80%, paying $54,400 of the $67,000 bill.
"I would sincerely like to thank Karen Fessel and her team at the Mental Health and Autism Insurance Project for helping us appeal a denial by our health insurance company for our child's 9 week psychiatric hospitalization out of network. It has been a lengthy and difficult fight with our insurance over the past two years, to locate and pay for our child's mental health care. Karen and her team got our denial overturned, which saved us over $50,000. Our child's subsequent 8 week psychiatric hospitalization at a different facility out of state was paid for in full by our insurance. Thank you Karen and the MHAIP!"
MHAIP Appeals to CA DMHC for Overturn of ABA Services Denial
A 27 year-old woman in Northern CA with severe autism had been authorized to get ABA treatment in a non-network day treatment center that specialized in treating severe injurious behaviors by Kaiser in spring of 2020. Her mother requested that services be stopped during the pandemic, and was explicitly informed that they could be restarted whenever she asked. She requested to resume services early in 2022, and was told that she needed a new assessment, and that it would be by an in-network program. The new program developed a treatment plan that included parent training only. MHAIP appealed, arguing that there was no evidence to support this treatment for an adult with this profile. Kaiser denied. The case then went to the CA DMHC, where it was overturned without requiring external review.
"Karen, you are a fighter, extremely resilient, and compassionate in the work that you do. I'd like to take the opportunity to thank you for a very strenuous process in obtaining the services for families with loved ones with disabilities. Your organization is highly reputable
and with great integrity. Again, thank you for your assistance, support, and your expertise." (Young adult pictured below)
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