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Dealing with Multiple Insurance Companies and the Department of Managed Health Care
I have taken two different insurance companies to the Department of Managed Care. The first case was against Pacificare Behavioral Health and involved "access" issues. It was "resolved" by an attorney. The second case was against Managed Health Network (MHN, a behavioral carve out of Health Net) and went to Independent Medical Review (IMR) through the Committee for Health Care Dispute Resolution (CHDR), a contract agency. It is very clear to me that the process is corrupt and cannot continue in its current state.
In the first case, Pacificare would not answer my requests in writing for names of speech, occupational therapists, and social skills therapists who had experience working with children on the autism spectrum in my service area. You cannot simply pick the name of a provider off a list. Children on the autism spectrum are not easy to work with, in fact, many providers do not work with them at all or completely lack the knowledge and experience. Attempts at therapy with such providers can in fact be emotionally damaging.
At first pass, the lawyer from the DMC sided with the insurance company. He believed everything the insurance company told him (much of which was not true). He had not even fully reviewed my file, which contained multiple written requests for names of experienced providers. The insurance company spoke with the DMC lawyer directly, they told him that they did not keep records of conversations with clients. They did not even have to submit their statement in writing. When I requested a copy of their response in writing (from the DMC lawyer), none was provided.
I received a letter telling me that the resolution was final, and the HMO had not violated the law in any way. I called anyway, and managed to persuade the DMC lawyer to re-read my case. He did, and the resolution he came up with was to allow the insurance company to reconsider their action (without any sanction), which they did, and they ended up paying for my son's speech therapy, OT therapy, and social skills therapy, with providers that I had selected (because they did not have anyone with the requested expertise). I should not have had to call this DMC lawyer/adjudicator (in fact, I was not supposed to). The insurance provider should not have been allowed to speak with the lawyer, outside of my presence. I should have been allowed to review their response to my complaint, as they obviously were allowed to review my complaint. It was a kangaroo court.
My second encounter with DMC involved MHN denying my son social skills group therapy as a treatment for his Asperger's syndrome. I followed through by sending in the denial and writing up a petition to the DMC. They in turn sent my petition on to the Committee for Health Dispute Resolution, for an "Independent" medical review. Though I cited AB 88 many times in my petition, no mention of the law was made in their response to me, and my son was ultimately denied therapy.
Here is the heart of my understanding of why they denied treatment:
"The Health Plan indicates that training in learning and social skills cannot be equated to treatment for a behavioral problem or mental disorder. Additionally, the Health Plan has determined that the treatment modality applied in this setting does not focus on acute symptoms but instead on long-term traits and behaviors and therefore does not meet medical necessity criteria."
"At issue in this case is whether the therapy at issue was/is medically necessary for treatment of the enrollee's medical condition. I have determined that the therapy at issue was/is not medically necessary for treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld."
The chronic nature of my son's condition was part of the basis of the denial. They also argued that the social deficits were of a learning nature (and thus should be an educational - school based intervention - my interpretation) rather than a treatment for a mental health condition. They could have made the same argument with speech/language therapy. Even if the intervention can be addressed in the school setting, it still does not get the insurance company off the hook. For kids with Asperger's, social deficits are at the heart of the difficulty. Both arguments (the chronic nature of ASDs and that the problem is of a "learning" nature) fly in the face of why the mental health parity law was enacted, which was to insure that people with mental health conditions were covered in parity with other medical conditions. Insurance providers can't stop paying for your insulin because it is chronic condition.
My current provider is Aetna. They declined to pay for my son's speech therapy. They said that it was not a covered benefit for his condition. That it is only covered to restore speech after stroke or head injury. I said that mental health parity requires that if they would pay for speech therapy for a person with a stroke, they are required to pay for speech therapy for a person with ASD's. After I read her the parity law over the phone, the customer service representative with whom I spoke said she would forward my claim, and I should hear back within 30 days. I am still waiting. I should not have to do that. If Aetna is licensed to provide insurance to people living in California, they need to know the laws which protect its citizens. Ignorance of the law (if it was in fact ignorance) is no excuse. They should be liable for sanctions, which perhaps can go into a pool which can pay for mental health treatments for the uninsured.
We have this law on the books. It behooves us to more carefully monitor how it is being carried out and enforced. Otherwise, what is the point? How is it protecting our citizens?
One final note is that when we sign up for insurance in California, we waive our rights to take our carriers to civil litigation and appear before a jury of our peers. Instead, we agree to arbitration. This shields the nefarious deeds of the insurance companies from public exposure. This cannot continue. Health insurers must be held accountable for how they treat their clients.
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Insurance Help for California Families 
