Dr. Denial = Death

By Dawn Roberts 01/06/15

Psychiatric treatment continues to be denied by insurance companies in unprecedented numbers, and addicts are dying as a result.

health insurance denial

Katherine West was a 14 year old with an eating disorder. Her condition was serious enough that her physician and psychiatrist ordered a 12-week stay of residential treatment, to which she was promptly admitted. Six weeks into therapy, the largest insurer in the United States (Anthem) decided that Katherine had gained “enough” weight and could be safely discharged from the hospital. Her treatment team vehemently disagreed with this assessment. The insurance company overruled the hospital and West was sent home for outpatient care. Less than a week later, the teen was discovered dead by her mother from heart failure caused by continued purging. Clearly, Katherine was not an appropriate candidate for the shortened stay determined by Anthem.

Despite passage of the Mental Health Parity Act in 2009, inequalities in healthcare coverage persist. Psychiatric treatment continues to be denied by insurance companies in unprecedented ratios compared with other health conditions. The implications of this disparity are particularly relevant to the recovery community. Addictions, including alcohol, drugs and eating disorders often require more time in treatment than insurance companies are willing to bear. The result is that treatment gets cut short, often with deadly consequences. The deeper issue at hand is the lingering perception of mental health concerns as moral failures. Voices for change are being raised, by former Congressman Patrick Kennedy and in mainstream media outlets, like 60 Minutes, where a December 14 story raised ire across the country.

Kennedy said, “It’s an all too familiar tragedy that mental health is not treated the same as the rest of physical health. It’s in the detail of how medical utilization reviews are made.” Health care companies are currently opaque in regard to their processes for denial. The former congressman has founded a non-profit organization called “One Mind.” The organization’s intent is to lead efforts in research, funding and public awareness of mental illness and brain injury. Kennedy’s vision is to bring government, corporate, scientific, and philanthropic communities together in a push to reduce the social and economic effects of mental illness and brain injury.

The statistics from the National Alliance on Mental Illness are telling: 9.2 million adults have co-occurring mental health and substance abuse conditions. One in four adults experiences mental illness every year and 13.6 million Americans live with chronic conditions such as schizophrenia, bipolar disorder and depression. To the extent that stigmas about mental illness and addiction can be removed, so goes our ability to manage the practices of health care companies. 

The type of review that resulted in the death of Katherine West works like this: After a patient is admitted into a treatment center, doctors begin receiving daily calls from a representative of the insurance company. If that representative decides the patient is ready for a lower level of care, the case is referred to an insurance company physician. This doctor, who has not met and will never meet the patient, reads the file, talks to the treatment team on the phone and renders a decision. 

Evaluations that change the course of care are done with alarming frequency in psychiatric and behavioral treatment. Insurance companies refer to the practice as as “managed care” but it is clearly about managing costs. Doctors are forced into dialogue with insurance companies on a daily basis to justify approval for patients to continue previously approved treatment. Questions are asked, like, “Is the patient acutely homicidal or suicidal?”  The questions are worded just so to ensure a doctor’s response of “no.” In a supervised setting and without a weapon, the patient is not in what is considered to be an acute condition.

The doctors providing assessments for insurance companies are generally not full-time employees. They are hired on a fee-per-review basis. This results in the contracted doctor working through cases at a rapid pace. In a recent incident documented by the show 60 Minutes it took a total of 55 minutes for a patient to be released to outpatient care, without one conversation occurring between the insurance provider and the hospital. The physicians contracted by Anthem have denial rates of 90% and above for behavioral treatment. While it sounds ludicrous, it is business as usual when it comes to managing the cost of treating psychiatric issues.

A doctor, Timothy Jack, was named in the 60 Minutes piece. Recordings of his denials in phone conversations reveal a disengaged voice, and comments peppered with the phrase, “This isn’t a personal matter.” Once a facility is denied coverage by insurance, an offer to accept cash for services is made to families. Choosing between raising tens of thousands of dollars or abandoning a loved one is distinctly personal. Dr. Jack’s office returned The Fix’s call for his perspective, but in light of pending litigation did not choose to make a statement. His representative did volunteer that we were “asking the right questions,” although it is not clear which questions he was referring to.

When insurance company doctors deny treatment, the firms claim a supervising physician oversees the process. According to CBS News, this is not true. In the case of Dr. Jack, his signature is on both an original denial and again as the supervising physician. The secondary documents are not signed by a human, but “robo-signed” by a computer.

It sounds outrageous, but former executives of Anthem insurance describe a system built on mutual professional distrust. This results in a game of poker where the recipient of a “bluff” is the insured. Dr. Paul Keith, a retired Anthem employee, indicated he thinks health care providers abuse health plans by making exaggerated claims regarding patient needs. It’s an adversarial relationship between sets of doctors. Keith claims that the setup is similar to the justice system, and that each side has the right to state its case. This is hardly the expectation of consumers paying for the security of knowing they will be cared for should a critical situation arise.

The U.S. Surgeon General reported that mental illness is the second highest cause of disability in the U.S., affecting over 20 million people. In the same report, it is estimated that half of those who require psychiatric treatment do not receive it because of stigma and lack of access to care. Dr. Shelly Sellinger is a psychiatrist in New York who treats a wide variety of conditions, including addiction. She has worked for over 20 years in hospitals, rehab centers and in private practice. She said, “Sending a client to inpatient treatment is not a polite suggestion. A psychiatrist knows the patient better than anyone. We’re aware of the level of care provided in a residential setting, and it isn’t recommended without cause.” It adds insult to injury when insurance companies approve a client for admission and then back-door engineer an early release to outpatient care based on cost.

The question remains, what can be done about these practices? Going nine rounds with an insurance company is sure to be a no-holds-barred match. However, when appealing coverage denial, there are tactics that may help support the insured’s position. Some problems are as simple as fixing the coding on a bill and can be sorted out by phone. Other disagreements are centered on complex and subjective medical opinions regarding treatment options. Understanding the procedure for appeals is critical to turning them in your favor. Every contact should be documented with notes and names of those spoken to. It’s also useful to have a copy of the insurance company’s complete benefits language, and comprehensive procedures for determining medical necessity.

A good strategy is to enlist the help of one of the non-profit organizations that work as insurance advocates. One group called Families USA has created a list of state resources that can offer specific guidance to insurance consumers. Benjamin Franklin said, “Energy and persistence conquer all things.” That may be the best advice to keep in mind before facing a managed cost expert at an insurance company. This is no time for parlor politesse. Get ready to dirty your hands and engage in some MMA style combat of the mental variety. Don’t be afraid to escalate the matter if it is not being addressed in the way you need it to be. Stay calm and polite, particularly when asking to speak to a call center supervisor.

The stigma attached to mental health treatment will not disappear of its own accord. Whether advocating for yourself, a spouse or family member, every voice that questions insurance company treatment disparities is a voice for change. The only wrong question is the one you don’t ask!

Dawn Roberts is a writer and media consultant. She lives in the Catskill Mountains with two dogs, a cat and a recording engineer. She last wrote about options to quit Suboxone, interviewed Bob Forrest and looked into the rehab abuse of adolescents.

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Dawn Roberts is a writer and media consultant in New York. Follow her on Twitter.