Guest guest Posted May 12, 2012 Report Share Posted May 12, 2012 Oh, , my thoughts and prayers are with you. I hope you can get these idiots to " see the light. " Have you contacted the International OCD Foundation? Google them. I think they are in Boston now. Perhaps they can help. Also Dr. Jenike, who is very involved with the foundation, might be able to help with your appeal. I have seen him speak at the national OCD conference, and he is just an amazing doctor and incredibly compassionate man. Also, NAMI (National Alliance for the Mentally Ill) might have advocates or ideas. Best wishes, (mom w/OCD, 12 yo dd w/OCD, 9.5 yo dd w/tics and possible just right OCD) ________________________________ To: Sent: Saturday, May 12, 2012 7:42 AM Subject: Second appeal denied! The second appeal was denied for my son to stay at 's. This time it was a different doctor from Blue Cross and he is also insisting my son is able to step down to PHP (Partial Hospitalization Program). The whole thing is just beyond ludicrous! We found out that our Blue Cross policy is " self-funded " by my husband's company. So that's both good and bad. Bad because this prevents us from being able to go to the state insurance commission to try and overturn the appeal, but good (maybe!) because my husband can go directly to the top level at his company to plead our case. I wrote a letter to the head of HR at his company detailing my son's conditions and explained that taking my son out of 's at this juncture would be akin to pulling the plug on a child on life support who had a great chance for recovery if given adequate time and proper treatment. I also stated that the two Blue Cross doctors who are denying my son's coverage have exhibited gross negligence with their decision and are essentially throwing my son out with nowhere to go because there isn't a PHP (partial hospitalization program) in this country that would accept a child in my son's condition. That is their argument, that my son is able to step down to PHP at this point. Of course, my son's doctor at 's repeatedly told them this is not an option as no PHP will take him, but they refuse to budge. To take my son from 's right now, there is absolutely NO question in my mind that he would decompensate very quickly and not only go back to square one, but may end up a lot worse than he was when we admitted him. I would seriously fear for his life! This child was basically a walking skeleton not more than a month ago (among other things) and as far as I'm concerned, these doctors at Blue Cross who denied coverage are akin to attempted murderers, there is just no other way to put it!! I will continue to fight this tooth and nail and will not stop until it gets resolved. The next step is a higher level appeal and I spoke with the senior rep at Blue Cross who is head of appeals for mental health. She seemed very empathetic to the situation and seems to " get it, " so we'll see what happens. She explained that this next appeal level enables me to submit " testimony " on my son and also enables 's to submit all of his medical records and notes. So I am in the process of putting together documentation, a timeline, etc., and will also send her a DVD with video clips of my son's tics, photos of friction burns on his arms from the tics, and other visuals that clearly show the severity of his situation. We can use many prayers right now... ------------------------------------ Our list ARCHIVES feature may be accessed at: http://health.groups.yahoo.com/group// by scrolling down to the archives calendar . Our LINKS may be accessed at http://health.groups.yahoo.com/group//links . Our FILES may be accessed at http://health.groups.yahoo.com/group//files . Our list advisors are Gail B. , Ed.D.(http://www.ocdawareness.com ), Dr. , Psychiatrist, and Tamar Chansky, Ph.D. ( http://www.worrywisekids.org ) You may ask a question of any of these mental health professionals by inserting the words " Ask Dr.(insert name) " in the subject line of a post to the list. Our list moderators are Castle, Barb Nesrallah and Becky Reynolds. You may contact the moderators at -owner . OCDKidsLoop membership may be accessed at http://health.groups.yahoo.com/group/ocdkidsloop/ . Our group and related groups are listed at http://health.groups.yahoo.com/group/ocdsupportgroups/links . Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 12, 2012 Report Share Posted May 12, 2012 Thanks so much, !! I will definitely check into your suggestions, I do know of Dr. Jenike. I don't know if he could help since he's not my son's doctor, but you never know so I think it's worth a try. NAMI is a great idea, I will contact them as well. I'm going to come at this from all angles and will not give up the fight until I win. There may be a lot of bloodshed in the battle, but hopefully it will the blood of Blue Cross and not mine (or my son's!)! > Oh, , my thoughts and prayers are with you. I hope you can get these idiots to " see the light. " Have you contacted the International OCD Foundation? Google them. I think they are in Boston now. Perhaps they can help. Also Dr. Jenike, who is very involved with the foundation, might be able to help with your appeal. I have seen him speak at the national OCD conference, and he is just an amazing doctor and incredibly compassionate man. Also, NAMI (National Alliance for the Mentally Ill) might have advocates or ideas. > > Best wishes, > (mom w/OCD, 12 yo dd w/OCD, 9.5 yo dd w/tics and possible just right OCD) > > ________________________________ > > To: > Sent: Saturday, May 12, 2012 7:42 AM > Subject: Second appeal denied! > > The second appeal was denied for my son to stay at 's. This time it was a different doctor from Blue Cross and he is also insisting my son is able to step down to PHP (Partial Hospitalization Program). The whole thing is just beyond ludicrous! > > We found out that our Blue Cross policy is " self-funded " by my husband's company. So that's both good and bad. Bad because this prevents us from being able to go to the state insurance commission to try and overturn the appeal, but good (maybe!) because my husband can go directly to the top level at his company to plead our case. > > I wrote a letter to the head of HR at his company detailing my son's conditions and explained that taking my son out of 's at this juncture would be akin to p > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 12, 2012 Report Share Posted May 12, 2012 , When I first started on this board many years ago there was alot going around about the turtle and how it was like our trademark because of the tough survival shell. It sounds like you are putting that shell to good use! I am certain you are exhausted, or maybe the exhaustion has not hit you yet, but what an incredible advocate you are for your son. You have got a humongous cheerleading squad right here on this board. My family and I will pray for you and your son every night, as well as for the members of the Blue Cross Appeals Board, that their hearts will be softened and that they will catch a little bit of the vision of what your son is going through and feel compassion. I love the idea of help from the OCD foundation as well as NAMI. After all, what are those organizations there for if not to help in the fight. I can't wait to read your email where the barriers were broken down and he is able to stay! Love and payers, To: Sent: Saturday, May 12, 2012 6:12 AM Subject: Re: Second appeal denied!  Thanks so much, !! I will definitely check into your suggestions, I do know of Dr. Jenike. I don't know if he could help since he's not my son's doctor, but you never know so I think it's worth a try. NAMI is a great idea, I will contact them as well. I'm going to come at this from all angles and will not give up the fight until I win. There may be a lot of bloodshed in the battle, but hopefully it will the blood of Blue Cross and not mine (or my son's!)! > Oh, , my thoughts and prayers are with you. I hope you can get these idiots to " see the light. " Have you contacted the International OCD Foundation? Google them. I think they are in Boston now. Perhaps they can help. Also Dr. Jenike, who is very involved with the foundation, might be able to help with your appeal. I have seen him speak at the national OCD conference, and he is just an amazing doctor and incredibly compassionate man. Also, NAMI (National Alliance for the Mentally Ill) might have advocates or ideas. > > Best wishes, > (mom w/OCD, 12 yo dd w/OCD, 9.5 yo dd w/tics and possible just right OCD) > > ________________________________ > > To: > Sent: Saturday, May 12, 2012 7:42 AM > Subject: Second appeal denied! > > The second appeal was denied for my son to stay at 's. This time it was a different doctor from Blue Cross and he is also insisting my son is able to step down to PHP (Partial Hospitalization Program). The whole thing is just beyond ludicrous! > > We found out that our Blue Cross policy is " self-funded " by my husband's company. So that's both good and bad. Bad because this prevents us from being able to go to the state insurance commission to try and overturn the appeal, but good (maybe!) because my husband can go directly to the top level at his company to plead our case. > > I wrote a letter to the head of HR at his company detailing my son's conditions and explained that taking my son out of 's at this juncture would be akin to p > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 12, 2012 Report Share Posted May 12, 2012 Oh , As I read through your post I got angrier and angrier. I can't begin to imagine how you must be feeling. This is beyond absurd. I think your idea of submitting a dvd is an excellent tactic....they need to see this first hand. Perhaps the personal aspect of your husband going to the top level at his company will bring some humanity and compassion to this. I am so sorry. Lee Second appeal denied! The second appeal was denied for my son to stay at 's. This time it was a different doctor from Blue Cross and he is also insisting my son is able to step down to PHP (Partial Hospitalization Program). The whole thing is just beyond ludicrous! We found out that our Blue Cross policy is " self-funded " by my husband's company. So that's both good and bad. Bad because this prevents us from being able to go to the state insurance commission to try and overturn the appeal, but good (maybe!) because my husband can go directly to the top level at his company to plead our case. I wrote a letter to the head of HR at his company detailing my son's conditions and explained that taking my son out of 's at this juncture would be akin to pulling the plug on a child on life support who had a great chance for recovery if given adequate time and proper treatment. I also stated that the two Blue Cross doctors who are denying my son's coverage have exhibited gross negligence with their decision and are essentially throwing my son out with nowhere to go because there isn't a PHP (partial hospitalization program) in this country that would accept a child in my son's condition. That is their argument, that my son is able to step down to PHP at this point. Of course, my son's doctor at 's repeatedly told them this is not an option as no PHP will take him, but they refuse to budge. To take my son from 's right now, there is absolutely NO question in my mind that he would decompensate very quickly and not only go back to square one, but may end up a lot worse than he was when we admitted him. I would seriously fear for his life! This child was basically a walking skeleton not more than a month ago (among other things) and as far as I'm concerned, these doctors at Blue Cross who denied coverage are akin to attempted murderers, there is just no other way to put it!! I will continue to fight this tooth and nail and will not stop until it gets resolved. The next step is a higher level appeal and I spoke with the senior rep at Blue Cross who is head of appeals for mental health. She seemed very empathetic to the situation and seems to " get it, " so we'll see what happens. She explained that this next appeal level enables me to submit " testimony " on my son and also enables 's to submit all of his medical records and notes. So I am in the process of putting together documentation, a timeline, etc., and will also send her a DVD with video clips of my son's tics, photos of friction burns on his arms from the tics, and other visuals that clearly show the severity of his situation. We can use many prayers right now... Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 12, 2012 Report Share Posted May 12, 2012 , sort of speechless, hate this! But then they aren't looking at your son's specific case probably, just looking at their " average " statistics or whatever insurances look at and figure he's been there long enough. Ugh! I would stress the severity of his case, that they need to look at his INDIVIDUAL treatment needs, that he is not yet progressed to " moderate " OCD where he would be ready for PHP. Not all patients progress in 6 or 8 weeks enough, blah, blah. And go on about relapse/decompensating, etc. They can get him well NOW or be paying more later over much more time when he'll need to return and/or his treatment is going to take much longer.... Found this when looking around for OCD residential treatment stuff, this is from a treatment paper: Our overall goal is for patients to complete at least 75% of their hierarchy during their treatment stay. If this goal is met, our outcome studies show that the individual has an 83% chance of maintenance of the gains made during treatment. Prior to discharge, the treatment team will develop a plan for continuing care, which may include partial hospitalization, outpatient therapy, family therapy and support groups. ------ So is he even anywhere near the " 75% " yet? doubt it. http://www.ocfoundation.org/uploadedFiles/Intensive_Treatment_Programs/Wisconsin\ %20-%20Brad%20Riemann.pdf And if his doctors don't feel he's ready...do they not LISTEN to doctors? Oh, makes me so mad! ((hugs)) do keep us updated! > > The second appeal was denied for my son to stay at 's. This time it was a different doctor from Blue Cross and he is also insisting my son is able to step down to PHP (Partial Hospitalization Program). The whole thing is just beyond ludicrous! > > We found out that our Blue Cross policy is " self-funded " by my husband's company. So that's both good and bad. Bad because this prevents us from being able to go to the state insurance commission to try and overturn the appeal, but good (maybe!) because my husband can Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 12, 2012 Report Share Posted May 12, 2012 I, too, will hold you and your son in my thoughts and prayers. It is absolutely sickening how insurance doctors can make such determinations which are clearly based solely on saving money, not saving lives. I wish we could expose this to the newspapers. It is just plain disgusting. My friend's son had severe acting out due to Aspergers and maybe mental health issues. Her school district first placed him in a school for those like him, but when it was so clear that he was too out of control for that, they paid for him to go to a residential treatment school for all of high school. They paid for everything. This may be a route you need to take, i.e. getting an educational attorney to handle this. Clearly, your son can't get an appropriate education while he is this symptomatic, so it is incumbent on the school district to pay. Second appeal denied! The second appeal was denied for my son to stay at 's. This time it was a different doctor from Blue Cross and he is also insisting my son is able to step down to PHP (Partial Hospitalization Program). The whole thing is just beyond ludicrous! We found out that our Blue Cross policy is " self-funded " by my husband's company. So that's both good and bad. Bad because this prevents us from being able to go to the state insurance commission to try and overturn the appeal, but good (maybe!) because my husband can go directly to the top level at his company to plead our case. I wrote a letter to the head of HR at his company detailing my son's conditions and explained that taking my son out of 's at this juncture would be akin to pulling the plug on a child on life support who had a great chance for recovery if given adequate time and proper treatment. I also stated that the two Blue Cross doctors who are denying my son's coverage have exhibited gross negligence with their decision and are essentially throwing my son out with nowhere to go because there isn't a PHP (partial hospitalization program) in this country that would accept a child in my son's condition. That is their argument, that my son is able to step down to PHP at this point. Of course, my son's doctor at 's repeatedly told them this is not an option as no PHP will take him, but they refuse to budge. To take my son from 's right now, there is absolutely NO question in my mind that he would decompensate very quickly and not only go back to square one, but may end up a lot worse than he was when we admitted him. I would seriously fear for his life! This child was basically a walking skeleton not more than a month ago (among other things) and as far as I'm concerned, these doctors at Blue Cross who denied coverage are akin to attempted murderers, there is just no other way to put it!! I will continue to fight this tooth and nail and will not stop until it gets resolved. The next step is a higher level appeal and I spoke with the senior rep at Blue Cross who is head of appeals for mental health. She seemed very empathetic to the situation and seems to " get it, " so we'll see what happens. She explained that this next appeal level enables me to submit " testimony " on my son and also enables 's to submit all of his medical records and notes. So I am in the process of putting together documentation, a timeline, etc., and will also send her a DVD with video clips of my son's tics, photos of friction burns on his arms from the tics, and other visuals that clearly show the severity of his situation. We can use many prayers right now... ------------------------------------ Our list ARCHIVES feature may be accessed at: http://health.groups.yahoo.com/group// by scrolling down to the archives calendar . Our LINKS may be accessed at http://health.groups.yahoo.com/group//links . Our FILES may be accessed at http://health.groups.yahoo.com/group//files . Our list advisors are Gail B. , Ed.D.(http://www.ocdawareness.com ), Dr. , Psychiatrist, and Tamar Chansky, Ph.D. ( http://www.worrywisekids.org ) You may ask a question of any of these mental health professionals by inserting the words " Ask Dr.(insert name) " in the subject line of a post to the list. Our list moderators are Castle, Barb Nesrallah and Becky Reynolds. You may contact the moderators at -owner . OCDKidsLoop membership may be accessed at http://health.groups.yahoo.com/group/ocdkidsloop/ . Our group and related groups are listed at http://health.groups.yahoo.com/group/ocdsupportgroups/links . Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 12, 2012 Report Share Posted May 12, 2012 I'm so sorry they are putting you through this! It's outrageous! Sounds like you will bombard them with information which should get their attention. Would it help to also speak with the nearby PHPs? That way you could also tell the insurance that the PCPs felt they would not be able to admit your son into their program? Hang in there! Fay > ** > > > , sort of speechless, hate this! But then they aren't looking at your > son's specific case probably, just looking at their " average " statistics or > whatever insurances look at and figure he's been there long enough. Ugh! > > I would stress the severity of his case, that they need to look at his > INDIVIDUAL treatment needs, that he is not yet progressed to " moderate " OCD > where he would be ready for PHP. Not all patients progress in 6 or 8 weeks > enough, blah, blah. And go on about relapse/decompensating, etc. They can > get him well NOW or be paying more later over much more time when he'll > need to return and/or his treatment is going to take much longer.... > > Found this when looking around for OCD residential treatment stuff, this > is from a treatment paper: Our overall goal is for patients to > complete at least 75% of their hierarchy during their treatment stay. If > this goal is met, our outcome studies show that the individual has an 83% > chance of maintenance of the gains made during treatment. Prior to > discharge, the treatment team will develop a plan for continuing care, > which may include partial hospitalization, outpatient therapy, family > therapy and support groups. ------ So is he even anywhere near the " 75% " > yet? doubt it. > > http://www.ocfoundation.org/uploadedFiles/Intensive_Treatment_Programs/Wisconsin\ %20-%20Brad%20Riemann.pdf > > And if his doctors don't feel he's ready...do they not LISTEN to doctors? > > Oh, makes me so mad! > > ((hugs)) do keep us updated! > > > > > > > > > The second appeal was denied for my son to stay at 's. This time it > was a different doctor from Blue Cross and he is also insisting my son is > able to step down to PHP (Partial Hospitalization Program). The whole thing > is just beyond ludicrous! > > > > We found out that our Blue Cross policy is " self-funded " by my husband's > company. So that's both good and bad. Bad because this prevents us from > being able to go to the state insurance commission to try and overturn the > appeal, but good (maybe!) because my husband can > > > Quote Link to comment Share on other sites More sharing options...
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