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Recent Appeal Wins by MHAIP
Network Exception and Auth Obtained for 110 Days and Ongoing of RTC
A 17 year-old girl with anxiety, OCD and panic disorder from South Carolina was denied residential mental health treatment, allegedly because the facility was out of network, and because there was an illegal exclusion for residential treatment. Courts have found that residential treatment is part of the continuum of mental health treatment and should not be categorically excluded from treatment. We appealed on an expedited basis and requested a network exception, because there were no appropriate facilities available from the plan, BCBS of South Carolina. The member did in fact have out of network benefits. Obtaining a network exception means the Plan reimburses at the in-network rate, which makes a material difference in the reimbursement rate for the family. The plan overturned their denial, and authorized 110 days and ongoing.
MHAIP Wins Medical Necessity Overturn and Reimbursement of $125k
MHAIP has recovered over $125k of clinically necessary residential treatment costs from Premera, acting as plan administrator for a major tech employer. The patient, a fourteen year-old girl, was admitted to a residential treatment center in NH for a four month stay. The health plan’s denials gave no consideration to the individual circumstances. Instead, Premera’s denial was based on a narrow, misapplied interpretation of evaluation timelines and treatment criteria, failed to consider the comprehensive clinical evidence, imposed undue limitations in violation of mental health parity, and overlooked both the accredited status of the facility and documented positive treatment outcomes.
Both denial letters relied on a “medical necessity requirement” of immediate access to a psychiatrist. They failed to consider the nurse assessment of psychiatric symptoms that took place on admission. The first level denial also cited a brief home visit for the holidays and a requirement for daily access to a clinician (which was in fact documented) as grounds for non-payment.
Premera uses both Interqual and its own policy known as "Psychiatric and Other Specified Evaluations in Inpatient and Residential Behavioral Health Treatment”. MHAIP filed a mental health parity disclosure request, citing this additional policy as a Non-Quantitative Treatment Limitation, in its wording and its operation. Some of the policy wording conflicted directly with the plan manual.
Shortly after denying the second appeal, but before supplying a comprehensive response or a comparative analysis, Premera told the member that the claims would be paid.
We are seeing health plans frequently cite their own strict clinical requirements as a component of “medical necessity”. Often this goes further than the generally accepted standards of care such as CALOCUS, which we also cited in our appeals here. We see this as another health plan workaround to prevent a full and fair review of a patient’s individual history and response to treatment. We will continue to file requests and complaints based on the mental health parity rules and refer employers to the Department of Labor when they do not meet their obligations. So far, despite many cuts in federal agencies, we are not noticing a slowdown in the activities at the Employee Benefits Security Administration.
Single Case Agreement Won for Entire RTC Stay
MHAIP successfully helped the mother of an adolescent female who was adopted at age 6 month and had been struggling with Reactive Attachment Disorder (RAD) and trauma. Multiple, years-long outpatient therapies and medication trials were not effective, leading her therapeutic team to recommend residential treatment specializing in treating RAD and trauma. When her mother began researching options with her insurer, UHC, she was unable to find a program to meet her daughter’s rather unique needs. She then located an out-of-network provider, and her daughter admitted there. The facility requested pre-authorization with a Single Case Agreement (SCA) upon admission. UHC authorized residential level of care but, in essence, blocked the request for an SCA by telling the facility that the member was required to use her out-of-network benefits. Within a few days, her mother made the request for an SCA again, which was then denied by UHC, again stating that the member could be treated in-network or use her out-of-network benefits. MHAIP wrote an appeal arguing that Plan documents allowed for in-network benefits if the network was inadequate. Her mother had excellent records of conversations with the insurer, lists of in-network facilities provided and researched, and letters of medical necessity from at home providers. MHAIP requested and received a strong letter of medical necessity from the treating therapist at the residential facility, which we believe was very helpful. We won the appeal, and the claims will be reprocessed at the allowed in-network rate, which will be a material financial benefit for this family.
“I recently dealt with an extremely frustrating situation with UHC attempting to get a single case agreement for an out-of-network trauma-focused RTC for my daughter. Despite ample evidence that my daughter desperately needed a program that specializes in trauma, my insurance denied my request stating that an in-network facility focused on eating disorders had availability. I spent over 40 hours explaining that she doesn’t have an eating disorder, but they remained adamant that the in-network facility was appropriate and indicated that I needed to move her there from the trauma-focused RTC. I refused and paid $35,000 out-of-pocket for my daughter’s 5-week stay at the out-of-network program.
I connected with MHAIP after my daughter had been discharged. At that point, I was feeling hopeless that I would recoup that money, worn out from dealing with UHC and generally exhausted by what had been a tremendously difficult period for my family. From my first call with Karen, though, it was clear that working with her and Marcy would be the opposite of dealing with my insurance! They were extremely knowledgeable, thorough, and efficient. They knew exactly what documents they needed from me, the RTC and my insurance. They even clarified for the insurance that we had the right to access certain information when they declined to share it! And ultimately, their appeal was successful! I’m immensely grateful to them. They are a beacon of light in the dark, dark world of insurance coverage for mental health."
MHAIP Secures Full Reimbursement from NY HMO
A 15-year-old girl from New York with OCD, Generalized Anxiety Disorder who suffered from severe panic disorder admitted to a program in NH that specializes in treating OCD and Anxiety. MHAIP requested prior authorization with a Network Exception, to which the family’s HMO agreed. It took 2 months for the insurer, Fidelis Care, to reach out for rate negotiations. MHAIP explained to Fidelis Care that the facility does not work with insurance in any way, including rate negotiations or accepting payments, and as Fidelis Care agreed to a Network Exception, they were required to pay the full daily rate – to which they agreed. Fidelis Care then indicated that they were not able to reimburse the family directly and stopped responding to our efforts to contact them. Fidelis Care began to issue reimbursement payments to the facility and at a low out-of-network rate. MHAIP filed an appeal requesting payment at the full per diem to the family, as agreed. We lost the appeal, with Fidelis Care alleging they could not “substantiate the allegations from the grievance…no adjustments will be made…” MHAIP then filed a complaint with the NY State Department of Financial Services describing the situation and pointing out that failure to pay the full daily rate for an HMO that authorized out-of-network services amounted to balance billing. The NY DFS investigation resulted in the family being contacted by Fidelis Care and told that the claims would be reimbursed directly to the family, but that “management” was still determining the reimbursement rate. A week later, Fidelis Care communicated that they would reimburse at the full daily rate paid by the family. Our efforts resulted in the family receiving the full reimbursement of $128K vs approximately $42K that Fidelis Care was attempting to reimburse, a material $85K difference.
“We are so grateful to Karen, Marcy and Allison for their patience, persistence, and hard work in helping us get the reimbursement that we were owed for our daughter’s stay in residential treatment. Because of them, we were able to keep our interactions with insurance workers, who had neither adequate knowledge of our situation nor compassion for what we were going through, to a minimum. Because of MHAIP, we were able to focus our energy not on fighting with our insurance company, but rather on our daughter’s mental health. We never would have gotten through this process without them.”
Two Months of RTC Care Won in External Review
The external appeal process is where we have most of our success in overturning medical necessity denials, and it was a sweet victory to win full coverage of the final two months of a young adult’s stay at an RTC in NH in an external appeal. Due to her autism, mood, depression, and anxiety issues, this young woman needed a longer-term program that specialized in complex cases and multiple diagnoses. The program's detailed record-keeping allowed us to make a persuasive and evidence-based case that she continued to require residential treatment level of care through discharge.
MHAIP Appeals Get Approved RTC Care Paid
When Aetna refused to pay on an approved 30 day claim for the beginning of a teen’s long-term residential stay claiming that they could only pay the claim after he discharged, MHAIP appealed, citing the New York state prompt payment law. After two internal appeals, Aetna overturned its decision and promptly paid the claim plus $1000 interest due to the late payment.
Network Exception and Medical Necessity Overturns Won with Complaints to State of CT Insurance Department
The mother of an 18-year-old Connecticut resident with coverage from a marketplace plan with ConnectiCare sought in-network options for residential treatment for her son with ASD, Bi-Polar II Disorder, Generalized Anxiety Disorder, ADHD and OCD. ConnectiCare provided names of only 2 facilities in CT. When his mother called them, she learned that neither facility treated ages 18 and older; therefore, they were not an option. His mother then identified a program in NH that would meet her son’s specific treatment needs. MHAIP requested prior authorization and a Network Exception, given ConnectiCare’s inability to provide a suitable in-network option. ConnectiCare authorized his care but denied the Network Exception. MHAIP filed an expedited appeal which ConnectiCare denied again, wrongly stating that because the member had out-of-network benefits, the only option was reimbursement at the out-of-network rate. MHAIP quickly filed a complaint and request for an external review with the State of CT Insurance Department. Before the case had a chance to go to an external reviewing agency, ConnectiCare’s medical director overturned their denial and authorized his care with a Network Exception. Just one week later, ConnectiCare denied his ongoing care in the concurrent review process. Again, MHAIP filed an appeal with ConnectiCare arguing the member continued to meet medical necessity, and again we lost the appeal. Again, MHAIP filed a complaint and a request for an expedited external review. Again, MHAIP, won an overturn from ConnectiCare’s medical director before the case ever got to an external reviewing agency. These efforts to hold ConnectiCare accountable to the terms of the member’s plan resulted in 112 of 120 days of care covered at the in-network rate. This is a substantial difference in reimbursement rates and secured the additional amount of approximately $82K for the family. MHAIP seeks to leverage the assistance of state regulators whenever possible and we frequently find it invaluable.
MHAIP Wins 21 Days of Inpatient Level of Care on Level 2 Appeal
Aetna denied the final 21 days of hospitalization for a 15-year-old male with diagnoses of ASD, ADHD, Generalized Anxiety Disorder and Other Psychoactive Use Disorder. The youth admitted to Huntsman Mental Health Institute, in-network for his plan, for stabilization and assessment and his care was covered for the first 28 days. MHAIP carefully reviewed the medical records for the denied dates and wrote a detailed appeal highlighting the many unsafe behaviors during the date range, including an episode requiring police intervention and his appearance at Juvenile Court. MHAIP won an overturn with the appeal and Aetna agreed to reimburse the family for the 21 denied days of service. Aetna then failed to process the member’s claim for those dates past the required 45-day response window. After calls to Member Services failed to get a response, we advised the family to leverage support from the employer’s HR department given that it is a self-funded plan. The employer got involved on behalf of the family and payment has finally been made.
Highlights of Pre-Authorization/UR Services
A 20-year-old from MD with ASD level 1, received 378 (to date) days of coverage from Care First BCBS at a residential treatment center in Utah.
A 16 year old from Hawaii with Generalized Anxiety Disorder, Major Depressive Disorder and ADHD received 126 days of coverage from HMSA at a treatment center in New Hampshire.
A 16 y/o from NY with OCD and GAD received 116 days of coverage by Fidelis at a treatment facility in New Hampshire.
A 15 y/o from CA with ADHD and other specified depressive disorder received 53 days of coverage by Anthem at a treatment facility in Hawaii
A 14 y/o from CT with OCD & ADHD received 78 days retroactive at a treatment facility in New Hampshire.
A 14 y/o from CA with ADHD and other depressive disorder received 53 days of coverage by Anthem at a treatment facility in Hawaii.
A 19 y/o from TX with Generalized Anxiety Disorder & ADHD received 99 days of coverage from Anthem at a treatment facility in New Hampshire.
An 18 y/o from CT with Autism Spectrum Disorder, Bipolar II disorder, Generalized Anxiety Disorder and ADHD received 102 days of coverage from ConnectiCare/Optum at a treatment facility in New Hampshire.
A 17 y/o from CO with OCD, ADHD and Generalized Anxiety Disorder received 63 days of coverage from UMR at a treatment facility in New Hampshire.
A 17 y/o from MT with MDD, social anxiety disorder, Disruptive mood dysregulation disorder and autism received 93 days of coverage from AETNA at a treatment facility in Hawaii.
A 17 y/o from Virginia with Major depressive disorder, Generalized anxiety disorder, Gender dysphoria and Agoraphobia received 78 days (to date) from AETNA at a treatment center in New Hampshire.
A 16 y/o from SC with GAD , ADHD, Avoidant Restrictive Food Intake D/O and Specific Learning Disability in Math received 89 days (to date) from BCBS at a treatment center in New Hampshire.
A 14 y/o from NH with Autism, GAD, Tourette's, MDD, ADHD and Panic Disorder received 33 days (to date) from United at a treatment center in New Hampshire.
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