Re: Why Insurance Companies are so Scary!

May 20, 2012

YOU GO GIRL!!!

That your insurance company seems to be hiding behind some criteria, or

categorizing your son in such a way to justify further funding for treatment is

despicable, and ultimately very sad.

While we have universal health coverage in Canada, there is very limited actual

" treatment " available for OCD, ie. ERP therapy with a qualified expert. What is

available, through the system, you will wait from 8 months to 2yrs to access -

only to learn they don't really have what you need - been there, done that!

Inpatient/Residential treatment doesn't exist here.

Private psychologists are not covered under our universal health care, some have

private that covers about 7 visits. I suspect the insurance companies know very

well what they are doing. Treating OCD properly, esp severe OCD, can be

expensive.

In my view, and have heard others state this, it is a human rights issue. How

can the life of a child with cancer be valued and allocated funding and

treatment - that I don't think is short term or inexpensive, and a child with a

mental health issue is not. The answer has many layers, and we are starting to

address this in Canada, but in the mean time, we as parents absolutely have to

demand care for our children NOW, so that eventually it WILL show up.

So, again - YOU GO GIRL - you are enlightening the powers that be on behalf of

many!!! Keep us posted, I'm sure you will, and know that we are right there

with you wanting the same.

Warmly,

Barb

>

> I have been busy researching for the insurance appeal for my son at 's. I

come to find out that apparently less than 25% of the population will ever

appeal or pursue a denial of coverage. Now I can understand that statistic if

it's a few hundred dollars, but apparently people even in my situation where

there is huge financial risk will not pursue a denial because they just don't

know how or what to do. So insurance companies bank on that statistic when they

deny coverage such as in our situation.

>

> So here's the really scary (and unbelievable) part.......Insurance companies

use specific " guidelines " which come in the form of software packages where they

essentially go through a bunch of check boxes to determine coverage. After many

emails back and forth with Blue Cross, one of the senior reps finally sends me

two different documents that were supposedly used as guidelines in my son's

case.

>

> One is titled " other psychiatric disorders " and the other is " ADD and

Disruptive Behavior Disorders. " Okay, so he could fall under the first category,

but absolutely NOT under the second, but here's the clincher.........I find the

website for the company that issues these guidelines and they have 15 " guideline

groups " to choose from, including the above mentioned. Which guideline group did

Blue Cross *not* use as criteria??? " Anxiety Disorders " which specifically

includes OCD in that group. Yes, he has Tourette's, but Tourette's is a common

co-morbid condition of OCD and they are saying that the TS falls under the

" disruptive behaviors " disorder, which is complete BS because I looked it up.

>

> They reviewers at Blue Cross (supposedly psychiatrists) either have very few

brain cells in their heads and/or they purposely avoided using the " Anxiety

Disorders " Guideline Group because they knew it would make my son eligible for

continued coverage. But wait, there's more......

>

> The specific reasons for denial on the letter: " Based on the clinical

provided you did not meet medical necessity criteria for continued treatment at

this level of care based on the following: you were not reported as being an

imminent danger to self or others, you were not reported as being aggressive or

threatening, and there were no reports of psychosis or mania. "

>

> Really?? Well he's been at 's for 2 months and his case is reviewed by

Blue Cross on a weekly basis. In other words, Blue Cross has reviewed his case 8

times before denying it supposedly using the same criteria all along, including

when he was admitted. So according to what they're their " criteria " supposedly

is he never should have been approved for admittance in the first place. I

highly doubt they approved him for admittance and continued approving him 8

times over out of the goodness of their heart!!

>

> Furthermore, being an imminent danger to self or others and being aggressive

or threatening are *inpatient* criteria, NOT residential, and there is a

difference. All I can say is there will be many heads rolling by the time I'm

done with all of this!!

>

May 20, 2012

, great job advocating for your son. Thougt maybe thhe insurance company

allowed payment initially b/c he was a threat to self/others, more in an acute

or evaluation phase. Then after some time, determine he is not so acute and

refuse. It is very frustrating b/c like you say, they are looking at

criteria/numbers/data and it is easier to refuse treatment when you look at

numbers and don't have to believe that it is a real person you are making

decisions about. I always say if the person making decisions came and met these

kids, they would decide differently, unless they were so heartless.

I work with kids who need to have outside physical therapy, in addition to

school PT. We run into the most denials with the kids they deem chronic

(muscular dystrophy, CP). The parents who push the most eventually get coverage,

but parents get so worn out advocating and it is almost a full time job calling,

writing letters. Other parents don't have the time or energy and then give up.

Keep advocating b/c you are also helping all of those other kids who also need

help but don't have someone pushing for services for them.

I always think of the mental health parity law. That has been a huge help for

use. Prior to that, we could not afford services for my son. Now he can get

services and the law gives more dignity to people with mental illnesses.