September 2023

Favorable Trends in Appeals and Utilization Review


 

We have noticed an exciting industry trend: we are winning longer stays and more appeals!! After long periods of draught, we are seeing many more wins. 

 

To what is this attributed? Probably a combination of factors, including that we are seeing more severe cases, which may in part be a result of Covid. We work with MANY teens, who likely had certain pre-existing vulnerabilities which were exacerbated by the pandemic. Some did not learn well online, did little schoolwork, increased gaming habits, and isolated in their rooms. Some became combative or self-harming when parents tried to get them to do more activities. Many developed severe depression and became non-functional, requiring a change of environment and removal from screens. Thus the need for medium to long-term residential treatment to unlearn unhealthy coping skills that became ingrained. 

 

The pandemic also created greater awareness of increasing rates of mental health problems. This led both the federal government and many state legislatures to pass and/or enforce laws pertaining to mental health parity. For those with self-funded plans, the Employment Benefit Security Administration (EBSA) will now take complaints, and compliance with the Federal Mental Health Parity And Addiction Equity Act (MHPAEA) has become a priority. 

 

Thanks to The Wit Case (see new ruling), many state legislatures are requiring health plans to use criteria developed by non-profit professional societies rather than criteria developed in-house. The former tend to be more objective and less profit-motivated. Other litigation efforts have also had favorable rulings. If the costs to the health plans are high enough, pressure from litigation can bring about meaningful change within the industry. 

 

Maybe after 15 years in the industry, we are actually getting better at what we do? It is certainly possible, but my money is on the other factors!! Stay tuned!! 

Highlights From Recent Appeal Wins




Two Centers Covered in Full due to Lack of Network Adequacy


MHAIP won a total of 78 days for a teen with substance abuse, eating disorders, and depression at a residential mental health treatment center in Hawaii, as well as 122 days and ongoing, for the same teen at a residential treatment center in Utah, both with single case agreements. The teen was initially denied at the center in Hawaii because it was out of network and out of state. We appealed to both United and the Oregon Division of Financial Regulation, because United was unable to offer any mental health facilities in network or in state with available beds for teens.  Later, the teen transitioned to a longer term facility in Utah, where they were initially approved for two weeks, then denied. United alleged that the client was ready for discharge, but they continued to want to engage in dangerous substances, including opiates, and had lost two friends to accidental overdoses during the course of both stays. We appealed for the second center based on medical necessity. The external reviewer agreed that the client was not safe for discharge, and overturned the entire stay through discharge. The client remains in the program.  


Overturn of Denial for Lack of Accreditation and Medical Necessity


MHAIP successfully overturned the denial of residential mental health treatment for a teen male with depression, ADHD, and neurological challenges from Southern CA with Anthem of CA. The teen was denied his entire stay because the facility lacked accreditation.  The facility, however, obtained accreditation from the Committee on Accreditation of Rehabilitation Facilities (CARF) ten days into the member's stay. We appealed the denial, Anthem then changed their reason for the later part of the stay to not medically necessary. We requested intervention from the Department of Managed Health Care (CA state regulator), who then sent the case to independent medical review, where it was overturned. The remaining 46 days were covered.  


Entire 71 Day Stay Covered, BSOC still Refuses to Pay Amount from SCA


MHAIP won a single case agreement for a 71 day (entire) stay at a residential mental health treatment center in Hawaii, for a teen male with ASD, depression, and oppositional defiant disorder from Southern CA. Blue Shield of CA (BSOC) had no appropriate facilities in network or in state that could treat a teen with that profile.  Initially they approved the first 4 weeks, we appealed on an expedited basis, which BSOC denied. We later appealed to the Department of Managed Health Care -- they agreed that the case qualified for expedited status. Blue Shield ended up reversing their position, and agreed to pay for the entire stay. To date, Blue Shield has paid for slightly less than half of what they agreed to in a written single case agreement (SCA) that they signed with the provider. MHAIP took the case back to the DMHC for further regulatory intervention. We currently wait for Blue Shield to follow through and pay the full amount that they initially agreed to, and we hope that the DMHC will send the case to their Enforcement department so that fines can be levied for bad faith business practices.  


Female Teen Won Complete Stay at Preferred Single Sex Facility


MHAIP successfully appealed the case of a 15 year old girl with PTSD and depression who requested to go to a girls only residential treatment center in Southern CA. The teen had been previously sexually assaulted.  She had previously tried a multi-gender PHP program that was in-network with her HMO, but felt unsafe and it was not helpful. United denied, because the program was out of network, and their clinician insisted that a girls only program was not medically necessary.  United had no girls only facilities available within network adequacy requirements. We sent the case to DMHC, and they required that United pay in full for the entire 45 day stay.  


$64k for Family of 13 Year Old With Autism Spectrum Disorder


MHAIP assisted a family from Arizona with a 13-year old son with Autism Spectrum Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, and ADD secure an additional 108 days of ongoing residential care at a facility specializing in treating neurodiverse youth. Despite several occasions of extreme dysregulation, sometimes involving elopement attempts, while in the program, BlueCross BlueShield of Arizona denied care after the initial 42 days.  It took 2 appeals to win the overturn of the additional 108 days.  In addition, MHAIP argued that there were no appropriate in-network options for this adolescent and was able to secure a Single Case Agreement, which results in coverage at an arranged daily rate as if the program was in-network.  This makes a material difference in the covered amount, in this case securing over $64k for the family.


Overturn of Administrative Denial for 31 Days of RTC


MHAIP helped a young adult from OR win an overturn for an Administrative Denial of 1 month of residential level care.  This young adult with ASD, Anxiety and ADHD was denied care due to the insurer, United Healthcare, stating the facility was in an “authorization unavailable status” with the insurer, also referred to as a “Do Not Authorize” list.  We filed a Grievance explaining that just a few months after the dates of service in question, the facility was removed from the Do Not Authorize list at UHC and argued that there were no material differences in the facility from the denied dates to when the facility was removed from their list.  31 days of care were overturned and reimbursed to the family.


Additional 25 Days of RTC Level Care Won on Appeal


A 16 year old male from California, who identifies as female, was denied ongoing residential behavioral health treatment for not meeting medical necessity.  MHAIP filed an appeal and was able to secure an additional 25 days of care for this adolescent suffering from acute Post-traumatic Stress Disorder and ADHD.


MHAIP Appeal Wins an Additional 38 Days of RTC Care


A 16 year old from PA, with Autism Spectrum Disorder, Major Depressive Disorder, ADHD, and substance use history was denied ongoing care at a residential program specializing in the treatment of neurodiverse adolescents.  Despite endorsing daily suicidal ideation while in treatment and displaying great difficulty with the confines of the milieu, all documented in the notes by the facility, care was denied as not medically necessary.  MHAIP filed an appeal and won coverage of an additional 38 days of care.  Along the way, the insurer, Highmark of PA, committed violations such as refusing to supply transcripts of phone calls and not citing the medical necessity criteria used in the decision in writing in the denial letter.  MHAIP’s knowledge of ERISA and State regulations and chasing down policy details helps us hold insurers accountable.


50 Days of RTC Coverage for a Neurodiverse Youth


MHAIP won 6 ½ weeks of coverage at an out-of-network residential treatment center for a 12-year-old boy with autism and behavioral issues that made it impossible for him to live safely with his family. Anthem denied his stay on medical necessity grounds but MHAIP appealed with a comprehensive history of his issues and specific incidents while at the RTC that resulted in an overturn of the denial. MHAIP is currently appealing the final part of his stay at the RTC with the Department of Managed Healthcare.  


Low Reimbursement Rate and Incorrect Payments Resolved


In what may be one of our longest to resolve cases, MHAIP persevered to get a very high daily reimbursement rate (that was very close to the RTC's billed amount) for 15-year-old boy with autism's 13 month stay at a residential treatment center. This case had many twists and turns. The insurance company HealthPartners had many issues with the claims we submitted, which took months to resolve. They also arbitrarily set 60% as the amount they were going to reimburse the member. MHAIP objected to that low reimbursement rate and was able to negotiate a much higher daily reimbursement rate. Checks for the wrong amount were issued to the member, requiring follow up and correction. The member has received her last reimbursement check and is very pleased with the result.


70 Days Covered with a $27k Reimbursement


We submitted claims and kept the pressure on Independence Blue Cross of PA over a continued period of time. We were able to recover 70 days for a Philadelphia trans teen with ASD, anxiety, and PTSD. His Dad says it better:

“The hoops, walls, and dead ends our insurance company put in our way were endless and endlessly frustrating. Karen was with us every step of the way and, quite honestly, kept me from giving up more than once. Insurance companies have learned that most people eventually throw up their hands and walk away. Karen does not. Because of her, we received over $27,000 in reimbursement for a residential program in Hawaii. We are deeply grateful.”





Hightlights, MHAIP

Pre-Authorization/UR Services


MHAIP has a new team member, Allison Clark, with a Masters in Counseling dedicated to Pre-Authorization (UR)Services for our clients. We are having success with the UR process and also securing many "Single Case Agreements," also known as "Benefit Exceptions," or "In for Out." When an insurer does not provide an appropriate program option, we argue they have an inadequate network and care secured out-of-network must therefore be covered at the in-network rate. If we exhaust the Utilization Review (UR) process, the MHAIP team typically then takes on the appeal process for ongoing coverage. Take at look at our recent UR successes.


  • 14 year-old from Colorado with ADHD and Autism Spectrum Disorder received 54 days covered from Cigna ins while at a treatment center in Hawaii.


  • 16 year-old from Northern CA with ASD, ADHD, depression and anxiety received 68 days (entire stay) under a single case agreement with Cigna, because they lacked network adequacy, while at a treatment center in Hawaii.


  • 16-year old from Colorado with Major depressive disorder, Generalized anxiety disorder, Social Anxiety Disorder and Gender Dysphoria received 46 days covered from Optum/United while at a MH residential treatment center in New Hampshire. 


  • 17-year old from New York with Recurrent depressive disorder, Social Anxiety disorder and   Generalized Anxiety Disorder Received 72 days and ongoing covered by Excellus Blue Cross/Blue Shield while at a MH Residential treatment center in New Hampshire.  


  • 20-year old client from Massachusetts with Major depressive disorder, Generalized Anxiety Disorder and ADHD received 64 days (entire stay) covered by Blue Cross Blue Shield while at a residential treatment center in Hawaii. 


Meet Allison Clark, M.S.

Patient Advocate

Pre-Authorization/Utilization Review (UR) Services

Welcome, Allison!

Donate Now to our General Fund


The General Fund supplements our sliding scale program, pays for educational seminars and workshops for families and professionals, helps with policy work and allows us to provide free advice to families needing help with insurance.

Donate Now to our General Fund
Helping families, providers and facilities obtain medically necessary mental health and autism treatments through health insurance.
Visit our Website
Sign Up for our Newsletter
STAY CONNECTED
Facebook  Twitter  Instagram  Linkedin