MHAIP Case Wins
ABA Therapy Services for Child with Autism Fully Reimbursed After Repeated Provider and Insurer Errors
MHAIP worked with the CA Department of Managed Healthcare (DMHC) to get 8 months of ABA services for a young boy with autism correctly billed as in-network and also fully reimburse his mother $60,250 for her out-of-pocket payments. Anthem Blue Cross refused to acknowledge that the ABA provider was actually in-network when the services were provided, and also sent threatening letters to the mother about collecting partial reimbursement payments they said were made in error. Only by getting the CA DMHC involved were we able to unwind all of the mistakes and get the money reimbursed.
MHAIP wins 232 Days of RTC Level of Care for Young Trans Woman with Autism
Although it is rare, sometimes we win big in first-level appeals. We appealed the denial of RTC level of care for a teenage trans woman with autism from Colorado, and won 7 ½ months of coverage for her stay in RTC through Optum/UBH. UBH had initially put the facility on a do-not-authorize list. After much back and forth, issues between the facility and the health plan were resolved and the care was approved. The family is so relieved that this young woman's issues are being acknowledged and she can continue to get the support she needs with her complex issues.
Kaiser Agrees to Pay for Mental Health Hospitalization
MHAIP assisted the parents of a CA teen with Kaiser insurance who had enrolled at the Huntsman CAT program for stabilization and comprehensive assessment for his severe depression, OCD, panic disorder, and possible schizo-affective disorder. The teen had a long history of hospitalizations and mental health treatments. The family had obtained an authorization from the Kaiser's acute care mental health department in advance, along with an authorization number. Approximately ten days into his stay, however, his parents received a call from the billing department of Huntsman saying that they could not reach an agreement with Kaiser. MHAIP got involved, filed an urgent appeal with Kaiser and an urgent complaint with the CA Department of Managed Health Care (DMHC). Though Kaiser and Huntsman refused to sign an agreement, after much back and forth with the DMHC, Kaiser agreed to pay all billed charges minus the enrollee's cost shares.
"I'm grateful to Karen and the team at MHAIP for the rapid and effective response they mounted to our case. Thinking back to the months of correspondence and advocacy I did with my insurance company, I wish I would have brought them on sooner! I heartily endorse this service. Our insurance companies are a mess and our health system is broken and it is so unfortunate that it sometimes requires a professional advocate to get the job done -- we are grateful that we found a path forward thanks to MHAIP. "-- Amy
MHAIP Secures Single Case Agreement for Oregon Teen
A non-binary teen from Oregon was seeking residential mental health treatment from Optum/UBH for eating disorders, depression, and substance abuse. The parents reached out to the health plan to obtain the names of appropriate centers. UBH was unable to provide names of any centers with availability. The family located an out-of-network facility in Hawaii, and MHAIP called to request an authorization. UBH said that the facility was on a do not authorize list, and issued a denial. MHAIP filed an expedited appeal with United, they upheld their denial, without providing any further information. We got the Oregon Division of Financial Regulation involved, and after much back and forth with United, they authorized treatment, including a single case agreement. To date, the client has received 53 days of coverage.
"Our single case agreement would not have been possible to achieve without the help of the Mental Health and Autism Insurance Project. Karen engaged us with actions to take right away with the insurance company. She is incredibly efficient and persistent, communicating clearly with us each step of the way. We are so grateful for her support as we are able to focus on our priority of supporting our child in treatment while Karen moved the process forward."
External Review Overturn for Partial Hospital Program
A 16 year old trans man from CA, who had been diagnosed with severe depression, generalized anxiety disorder, OCD, Anorexia, history of self-harm, and gender identity disorder, was admitted to a partial hospital program. Approximately 7 weeks were approved, and then continued coverage was denied. Anthem determined that the teen was not at high risk for harm and only needed outpatient services. The client remained in treatment at personal expense, as he continued to battle self-harm urges. Two weeks after Anthem determined that he no longer needed treatment, he self harmed with a blade. Parents brought him to the ER where he was placed on a 5150 hold and transferred to a mental health hospital. MHAIP filed an external review, the case was overturned, and Anthem was ordered to pay for the last two weeks of the PHP stay.
$90k in Reimbursements Secured for Family of Texas Teen
A post-service review of 8 months of treatment for a Texas teen suffering from anxiety and major depressive disorder resulted in a denial of residential level of care; however, the denial letter expressly stated that the teen met criteria for partial hospitalization (PHP) level care. To recoup some reimbursement for the family, with approval from the insurer, BCBS of IL, we submitted corrected claims for PHP level care. After months of failure to process, or even acknowledge receipt of the corrected claims, we advised the family to request assistance from the former employer’s HR department. This pressure produced a contact with a customer service rep who ultimately got all the claims re-processed and paid.
“Back in April, 2022, we initiated a case to seek reimbursement for thousands of dollars spent for out of state treatment. I was cautiously optimistic that we had a solid case for reimbursement given our medical necessity. I am grateful for all the work you have done. Over and over again, we encountered claims processing people that tried to thwart, stall, or block our efforts as well as their incredible incompetence. I was tempted to give up more than once. Marcy was undaunted and remained focused. She is the reason we were able to get the reimbursement we did. We are a "use case" for perseverance. I had some concerns I would spend more than my reimbursement. Marcy convinced me our case had merit, and I am glad I trusted her.”
58 Days of Residential Treatment Authorized and Rate Grievance Win
MHAIP obtained authorization for 58 days of residential treatment for an OR transgender teen with Level 2 ASD at an out of network facility in UT. After several years of various outpatient treatments, ER visits with hospitalizations due to suicidal and homicidal ideation, and a 7-week RTC program this teen needed a higher level of care. Aetna did not have any programs in-network that would accept a transgender patient with Level 2 ASD. While Aetna authorized the facility, the RTC claims were reimbursed at an extremely low rate. MHAIP filed a grievance for the low reimbursement rate and won an overturn resulting in an additional payout to the family of $17k.
BCBS North Carolina Acknowledges Inadequate Network, Authorizes RTC Care
MHIAP secured authorization for 27 days of residential care for a 13-year-old teen with ASD, anxiety, depression and ADHD. While BCBS NC originally authorized the out of network facility, they refused to cover at the in-network rate. MHAIP appealed with documentation of the family’s good faith attempts to locate an in-network option for the teen. No in-network program was appropriate for his combination of diagnoses. After 2 levels of appeals, BCBS NC agreed to cover the claims at the in-network rate.