SCA for Residential Treatment for Northern CA Kaiser client 

A 15 year old teen from Alameda County, CA, with ASD and pathological demand avoidance (PDA) had refused all forms of outpatient therapy, had attended no school for several months, and was languishing at home.  Kaiser offered a WRAP program (intensive therapy based in the home), and a facility that had no expertise in treating Autism with PDA.  We appealed to Kaiser, who denied, alleging that the facility could offer an individualized plan.  There was a waiting list for the WRAP program.  We insisted that he needed milieu therapy with expertise in treating ASD, and filed an appeal with the CA Department of Managed Health Care (DMHC).  DMHC would not send the case to external review, wanting the client to try the facility that Kaiser offered.  Eventually, a space opened in the WRAP program, and the family tried it.  The program only offered a few hours a week, which was not enough to address his extreme issues.  When we informed DMHC of this, they ordered Kaiser to approve at least 60 days of services in the facility that had expertise in autism.  The entire process took over five months, and a lot of back and forth with DMHC.   

36 extra days granted 

MHAIP secured an additional 37 days of coverage for a female teen diagnosed with OCD, ADHD, agoraphobia and GAD. We reported on this case previously because we had asked for intervention from the state regulator (New York Department of Financial Services) to get the initial 82 days paid. 

Involving the regulator got the first period covered, but the remaining treatment period went on to a full external review for clinical necessity. The review organization, IMEDECS, noted that "outpatient levels of care had failed to provide a remission” and they accepted what we asserted, which was that the records showed it was medically necessary for the patient to remain in care after the point at which authorization had been withdrawn. They accepted that the treatment plan was clinically appropriate, and included a plan for safe discharge and eventual step down to lower level service. 

We are now trying to level up the paid amounts to the Single Case Agreement that was reached with the provider. Getting plans to pay what they have already agreed to is becoming an increasing problem as described in the lead story. 

ABA - Cuts in hours

MHAIP works with families who face cuts in their authorized hours of applied behavioral analysis. This happens more often as children age, and has at that time an acute adverse impact, if other programming is not available.  Even though California has a rule stating that Health plans may not deny medically necessary behavioral health treatment for autism spectrum disorder based on the availability of educational, social, or another non-healthcare services (regardless of age) our experience is that plans are highly likely to review and try to cut hours as children approach adulthood (cutting hours before 21 also ignores the requirements of the Early and Periodic Screening and Detection Treatment rules for Medicaid-eligible individuals). 

When a 19-year-old female with autism spectrum disorder saw her ABA treatment authorization abruptly withdrawn, we immediately filed an expedited external review with the DMHC. The health plan then self-referred out to an independent reviewer.  We won reinstatement of 30 hours.  We were unsuccessful in a further external review for reinstatement of the additional ten (using a different independent medical review organization). This case shows that external reviews still remain somewhat of a lottery. 

External Review Overturns Aetna Denial

As noted above MHAIP has been fighting an ongoing battle with Aetna and other health plans to pay for claims that they authorized ahead of time. In one case involving a teen female from NYC attending an RTC in Utah, Aetna requested medical records and then denied treatment based on quality of the submitted records, stating that they did not support the treatment provided. 

Their concerns included the following: 

1) Daily progress notes sometimes lacked provider name/signature/credentials.

2) Dates that services were performed were not written on every page and

3) Lacking patient identifiers (member name, dob or ID#) on every page (this was readily easily addressed by records administrators) 

After Aetna denied previously authorized care through two rounds of appeals and numerous resubmissions of amended records, we fought and won the right to get the case submitted to external review.  The external reviewer found that the care was medical necessity, did not have any issues with the submitted records, and ordered the 49 days in dispute to be paid. 

Providers may want to reach out to their electronic medical records providers to make sure they are able to format the notes in ways requested by payers, and take care to ensure that all notes are appropriately entered, signed and logged by credentialed providers. Flexible systems which allow dates to carry over from one page to the next are desirable. If you have encountered these aggressive practice in denial of authorized care, please reach out to us and we can try to troubleshoot with you.