Utah Family Fights for Son’s Care After Insurance Denial

By Consumers For Quality Care, on June 26, 2019

Last August, the police showed up at Leah’s home in Utah. Her son had texted his friends that he was going to take his own life, so they had used the Safe Utah app to notify the police, KUTV reports.

Leah took her son to his longtime doctor. The doctor told Leah that he should go to a residential treatment facility to get the care he needed. Leah checked which facilities were in her insurer’s network and found one that had availability for her son. The treatment facility approved her son’s stay and they moved him in.

After he started treatment, Anthem, their insurer, decided that a residential treatment facility was not “medically necessary” and notified the family that his care could be handled elsewhere.

“He was not stable,” said Leah. “He was having suicidal ideation, talks of running away while he was in there. You don’t pull out a patient who just had heart surgery and say ‘hopefully he’ll make it.’”

Despite the denial, Leah made the decision to keep her son in the 85-day-long program to ensure he completed the full treatment. The family was then billed $88,000, with Anthem only paying a small fraction of the bill.

Leah tried appealing the decision by Anthem, but was denied. “The fight I’ve gone through, most people would have gave up long ago,” she said.

Leah’s frustration over the denial of her son’s treatment lead her to Holly Wheeler, a former lawyer who advocates for consumers. Like Leah, Holly has had to fight to get mental health care coverage for her son.

According to Wheeler, Leah did everything right. She says that parents of children in crisis should make sure to get a letter indicating a treatment’s medical necessity from a physician, obtain prior authorization whenever necessary, and regularly document their child’s progress.

“I spoke with a residential treatment facility yesterday who has a child in their care who is actually attempting to take their life, actively attempting to take their life while in treatment,” said Wheeler. “And the doctor for the insurance company says ‘I think it’s just dramatics.’ How can you say that to someone who’s got three physicians, including the ER doctor, who’s saying this child needs this, and this is from a doctor who’s never seen the kid, never reviewed the medical record. So if insurance companies wanted to take mental health seriously, claims would be paid.”

Heather Black works as an insurance coordinator for Sunrise Residential Treatment Center in Washington, Utah. The center focuses on helping teenage girls struggling with mental health issues. Black, too, is frustrated by insurers’ lack of willingness to pay for consumers’ treatments.

“They’re still A students,” Black said. “They still have a great social network. They’re still wonderful at home, and then their parents find them in the bathtub. [Insurance companies] want them to be actively harmful to themselves or somebody else. We don’t see that. They’re not going to go out and announce, ‘hey, I’m feeling suicidal’ and if they don’t do that, they don’t want to cover, and that’s what I would like to see change by the insurance companies. You can’t take a blood test. It’s not comparable to medical, and that’s where they want to stick it.”

After KUTV got involved in Leah’s case, Anthem responded with a statement that said the issue had been resolved and the family was not responsible for any additional charges. As part of the deal, Leah signed an NDA, which bars her from providing information on the agreement.

KUTV reports that as it investigated Leah’s case, several residential treatment facilities specializing in care for adolescent patients reported having a difficult time receiving payments from insurance companies.

Almost all told us that at some point, all claims will be denied, and it is incredibly rare for a patient to have an entire stay covered by insurance 100%.