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Recent Case Wins by MHAIP
MHAIP Wins Reimbursement Rate Appeal
MHAIP worked on a case involving Quantum Health’s inexplicably low “reasonable and customary” reimbursement rate of $60.45 per day for an authorized out-of-network Partial Hospitalization stay for a 14-year-old boy at a residential treatment center in Utah. We appealed this incredibly low reimbursement rate and included evidence that the standard rate for that region and level of care in the range of $300-$400 per day. This appeal, together with the boy’s mother’s strong advocacy and follow up with her insurance plan, resulted in a reimbursement of the high $400s/ per day for the boy’s 7-month stay at the facility.
MHAIP Wins Coverage for 76 Days of RTC, Family Recoups $82K
MHAIP helped the family of a 16-year-old female from NY suffering from acute anxiety with panic attacks, OCD and Major Depressive Disorder. United Behavioral Health denied ongoing residential treatment at a facility in NH, alleging that she had improved and no longer required that level of care. MHAIP reviewed the medical records in detail and agued that while her panic attacks had decreased in number, they were only beginning to be able to address her OCD in treatment, and that she still required the structure of the milieu. We lost the initial appeal with UHC and filed for an IMR (Independent Medical Review). We requested and received UHC’s internal case file and used information from there to prove that the member had not received the legally required “full and fair review,” ie that UHC had ignored many key details in her case in their denial. We won an overturn through the IMR process, securing coverage for her remaining treatment days through discharge, 76 days, recovering over $82k that the family had paid out of pocket so that their daughter could successfully complete her treatment.
29 Days of RTC Won in External Review for South Carolina Family
MHAIP won 29 days of residential mental health treatment in external review for the family of an 18-year-old from South Carolina with depression, panic attacks, anxiety and trauma. BCBS of South Carolina initially denied services because the facility did not have on-site 24/7 nursing care. We argued that this blanket exclusion was overly restrictive, was not aligned with evidence based standards, and there was no evidence to support its efficacy. The external reviewer agreed with us and ordered BCBS of SC to approve 29 of the 90 days provided. The plan, however, had not sent the complete file to the external reviewing agency. We have requested that the state regulator, South Carolina Department of Insurance, further investigate. We have asked the plan to pay for the full amount of treatment. To date, they have not even paid for the approved dates. We are hopeful that the South Carolina Department of Insurance will intervene and force the plan to comply. If you or your facility have been denied residential treatment because your facility or the facility where your child went lacked 24/7 nursing care, please feel free to reach out to us for a consult.
Overturn of Procedural Denial Secures 16 Weeks of RTC
MHAIP was able to recover full payment (less small deductible) for a 16 week medically necessary stay at a New Hampshire treatment center for a young man with a complex and severe psychiatric history. His admission to the intensive residential treatment program came after lesser levels of care had failed to address the complex interplay between his diagnosed mental health conditions, significant trauma, and ongoing danger to himself.
The neuropsychological evaluation stated explicitly that an intensive program was required, given that outpatient therapy, specialized schooling and even partial hospitalization had not provided lasting stability. At the same time as they saw him finally begin to make progress at the facility, the family had to deal with the stress of non-payment by the health plan (Blue Cross and Blue Shield of Massachusetts). Blue Cross had cited various procedural objections to the programming there, culminating in a denial letter which stated that the “facility does not provide at least 4 hours of structured clinical weekend programming."
In this case, the family had chat transcripts from before his admission, of the misinformation that was given to them about other so-called “requirements." This initially included that services would not be covered because the facility did not have on site nursing care 24/7, and that preauthorization needed to occur within 48 hours of admission, which had already passed. (Subsequent information included that authorization could occur within the first 90 days and that 24/7 on site nursing care was not a requirement so long as care was available on call.) Fortunately, the family was able to provide transcripts of some of the exchanges that taken place in the online portal.
We appealed to the health plan, providing a more detailed picture of the programming at the facility, but at the same time challenging the health plan’s specific requirements as overreach. We pointed to the fact that the weekends were specifically designed to allow participants to practice generalizing skills in the community, as part of their therapy. We also noted that the plan's own different definitions of care were confusing. Although we did not receive a formal overturn letter, we did see the authorizations renewed, and payments made promptly.
The effect of these stringent pre-requirements on facilities is an extra gateway to denial. Across the country, attorneys are taking note of these apparent “blacklists," and the spurious reasons that are given for blanket denials. When a health plan relies on such procedural reasons for denial, it prevents the case from going to full clinical review which is when the actual programming and individual response to treatment can be addressed. Early actions on three separate cases from the Northern District of Ill against Health Care Service Corporation (parent company to BCBS of IL and TX) for denying because Residential Centers lacked 24/7 nursing care have all survived motions to dismiss (1) (2) (3). We will continue to fight these denials and welcome all new referrals that can assist us tracking them.
Ongoing ABA Therapy Secured After Improper Denial
MHAIP was able to overturn a denial of Applied Behavior Analysis (“ABA”) therapy for an 11-year-old girl who had been receiving ABA continuously from the age of two. In 2024, the health plan (Blue Cross Blue Shield of Illinois) stopped paying claims and denied further authorizations. The family noticed an immediate effect on her progress, and a decline in her social flexibility, ability to focus, and her executive functioning. On appeal, the plan had stated that she did not meet medical necessity guidelines, because her social skills were “within normal limits, there was no danger to self or others, and problem behavior is still occurring about the same as when care stopped." MHAIP submitted an external review request to the state Department of Insurance, citing the CASP guidelines to support our assertion that Blue Shield's own policy was not in line with Generally Accepted Standards of Care, and pointing out that the most recent evaluation did in fact reference functional impairment and maladaptive behaviors.
In addition, we were able to cite extensive state parity rules in Illinois including that insurers should not be permitted to deny medically necessary mental health and substance use disorder care through criteria that are inconsistent with Generally Accepted Standards of Care. The CASP guidelines differ from the BCBS guidelines in that the CASP guidelines are consensus based and developed by a nonprofit professional society, and therefore it qualifies as Generally Accepted Standards of Care for the treatment of autism. Although the external reviewer did not cite the CASP guidelines specifically, they did agree with our contention that withdrawing authorization for ABA services was against the Generally Accepted Standards of Care. It is important to remember to ask for the health plan’s medical criteria – and to keep asking, even when the plan makes them difficult to obtain. Accessing and using the plan medical criteria is a critical part of the medical appeal process.
$150k Won Thus Far in Appeal
MHAIP continues to work with the family of a 17-year-old boy in residential treatment at an RTC in Utah. We recently won an additional three months of coverage from Aetna. This appeal has been very frustrating because Aetna refused to issue a denial letter for the RTC level of care, requiring many phone calls and ultimately, the submission of claims for his entire stay. Aetna asserted that they did not have to pay the claim until he discharged from the program, which in certain states and under ERISA (a federal law) is not permitted. MHAIP has also been able to obtain interest payments in plans regulated in certain states, including NY and CA. We will continue to appeal his entire 11 month stay at the program.
Network Exceptions
A network exception is a special arrangement where the health plan acknowledges that they do not have an adequate network to treat your child and they will allow you to use in network cost shares. Often insurers will pay the full amount billed. A single case agreement ("SCA") is similar, except that the provider reaches an agreement with the plan on a rate. During these difficult times, many health plans do not have adequate networks for mental health care. We encourage you to explore what is available in network before going out of network. If nothing is available, request an exception from you plan.
MHAIP successfully appealed denials for network exceptions for several clients (two with United Behavioral Health, one with Aetna, and one with BCBS of SC) at a residential treatment facility in NH which specializes in treating teens and young adults with Obsessive Compulsive Disorder (OCD). This program offers a high degree of expertise in this condition, a group of similar peers, Exposure Response Prevention Treatment combined with CBT, and other unique programming which is often not available in plan networks. If your facility has a particular specialty, or your child has challenges including neurodivergence, gender transitioning, psychosis, or other challenges that may require unique programming, we are happy to provide guidance on how to obtain these exceptions or SCAs.
Highlights of Pre-Authorization/UR Services
LB, a 14 y/o from NH with Autism, GAD, Tourette's, MDD, ADHD and Panic Disorder received 125 days authorized from United at a treatment center in New Hampshire.
KM, an 18 y/o from CT with GAD and MDD received 77 days authorized from United at a treatment center in New Hampshire.
JR, an 18 y/o from MA with Autism Spectrum Disorder, ADHD and MDD received 110 days authorized from BCBS of MA at a treatment center in New Hampshire.
SB, a 16 y/o from NY with ADHD, OCD, Agoraphobia and Social Anxiety DO received 83 days authorized by Health First NY at a treatment center in New Hampshire.
TV, a 17 y/o from NJ with Trichotillomania and GAD received 99 days authorized by United at a treatment center in New Hampshire.
NP, a 15 y/o from NC with GAD and ADHD received 85 days from Cigna at a treatment center in New Hampshire.
AT, a 17 y/o from ME with GAD and Social Phobia received 85 days from United at a treatment center in New Hampshire.
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