Blue Cross and Blue Shield of Minnesota says its coverage review decisions are appropriate
Blue Cross and Blue Shield of Minnesota says its coverage review decisions are appropriate
Signaling it doesn’t intend to go down quietly, Blue Cross and Blue Shield of Minnesota is aggressively defending itself against charges by Mike Hatch, state attorney general, that the plan engages in "a pattern of misconduct" in denying medically necessary health care treatment recommended by physicians for state children suffering from mental illness, eating disorders, and chemical dependency.
Mr. Hatch’s suit, filed Oct. 3, alleges that Blue Cross routinely attempts to sidestep its coverage obligations by inappropriately shifting the cost of caring for such children to taxpayers and/or their families, including instructing parents to have their children suffer "legal consequences" or to make "use of the juvenile justice system," instead of providing the care covered by the policy. The suit also alleges that in some cases Blue Cross instructs parents to place their children in foster care rather than provide medically necessary treatment. It gives six case illustrations of the Blue Cross actions specified in the suit.
Mr. Hatch declared it is "wrong for any HMO or health insurer to deny coverage for medically necessary health care treatment. The atrocity is magnified when the denials are imposed on children with mental illness and eating disorders. The families of these children aren’t always in a position to recognize the scope of their problems and certainly aren’t in a position to fight back against an insurer that restricts access to care."
Mr. Hatch’s complaint says Blue Cross and Blue Shield misrepresents its actual practices in its advertising, promotional materials, contracts, and policies and that its actions violate state consumer and insurance laws.
Blue Cross issued a brief statement Oct. 3 and asserted that the company’s goal is to get people back to their best possible health through individualized treatment programs. The company added that it pays for more than 94% of requested treatment, whether it is reviewed or not. Blue Cross appeared to take a more combative stance when it filed its reply brief with the Hennepin County Court and provided a rare look at its medical necessity review procedures.
Rebutting the charges
Mark Banks, CEO for Blue Cross and Blue Shield of Minnesota, says Mr. Hatch never approached the plan to discuss any potential problems or raise questions about the six patients cited in his illustrations.
"Instead, he chose to ignore the facts and grab the headlines. The six illustrations described in the complaint are not typical cases. From January through September 2000 alone, Blue Cross paid out more than $67 million in mental health and chemical dependency benefits for our members. Nearly one-third — $21 million — of these benefits was for mental health and chemical dependency treatment for children," Mr. Banks continues. "The attorney general suggests that the medical review process employed by Blue Cross is inherently suspect. Yet, the legislature has specifically endorsed the concept of utilization review and peer review with the enactment of comprehensive legislation. Furthermore, both the state of Minnesota and the federal government have adopted medical review for their own government programs."
In its legal filing, Blue Cross contends that "for a very small number of cases, the level of care [provided] was reduced to some degree or denied. This process includes the review of all information that is provided to Blue Cross by the families or facilities giving care. . . . Reduction in lengths of inpatient stays or denials may be determined [to be] appropriate when a less intensive setting can address the treatment needs of the patient, when outpatient care has not been attempted or fully explored, or when the facility has failed to demonstrate why a particular treatment or course of care is necessary to carry out the treatment plan for a specific patient."
Blue Cross says its process for assessing medical necessity in the context of managing mental health services is based on criteria researched and reviewed by a national multidisciplinary panel of clinicians for The Mihalik Group of Chicago. The criteria are submitted for review to licensed mental health clinicians at 10 Minnesota clinics that submit high volumes of claims to Blue Cross and to 10 internal, multidisciplinary staff of its behavioral care subsidiary, Behavioral Health Services Inc. The clinicians who participate in the review practice in Minneapolis-St. Paul and throughout Minnesota are child/adolescent specialists and generalists.
The review criteria for determining medical necessity, "which are endorsed by the mental health community and have been adopted by Blue Cross," require that a treatment or service be:
1. intended to identify or treat a diagnosable disorder that causes pain or suffering, threatens life, or a resulting illness as manifested by impairment in social, occupational, scholastic, or role functioning;
2. consistent with nationally accepted standards of medical practice;
3. individualized, specific, and consistent with the individual’s signs, symptoms, history, and diagnosis;
4. reasonably expected to help restore or maintain the individual’s health or to improve or prevent deterioration in the individual’s diagnosable disorder;
5. provided in the least restrictive setting that balances safety, effectiveness, and efficiency;
6. not primarily for the convenience of the individual, provider, or another party.
The plan calls for reviewers to focus on individual clinical presentations and treatment needs to determine the appropriate length of stay, rather than automatically approving lengths of stay based on predefined programs. "Blue Cross has clearly advised reviewers that [it] expects decisions to reflect the most appropriate treatment for a patient in the most appropriate setting. The physician consultants who perform peer review must agree to base the decisions on the appropriateness of the care/treatment and medical necessity of services and are not subject to incentives or quotas to reduce or deny care/services. Peer reviewers are paid solely for their time spent in reviewing a case."
Although the attorney general has not divulged the identities of the six patients referred to only by their initials in his complaint, Blue Cross says it determined that among its subscribers there are persons who match the attorney general’s descriptions in terms of diagnosis and treatment information. "But Blue Cross denies that the allegations accurately depict the investigations and reviews done by Blue Cross with respect to these patients." For each of the six, the company says, these steps were taken:
• The review processes were timely.
• The company reviewed all new information submitted to it for consideration.
• It followed its review and appeals processes.
• The company gave the provider timely notification of any denials so that the provider and the family could decide how to proceed with treatment.
"Blue Cross further denies that it consistently refused to provide coverage for any of the six patients’ requested treatment using dishonest or misleading tactics," the company adds. Blue Cross also insists it never said that any of the six were not in need of care. "The issue, to the extent that there was an issue, was about the level of care appropriate to the circumstances of each of these patients."
The plan also denies a specific charge by the attorney general that it told the parents of one of the illustrative patients that they should have the child arrested and then treated by government agencies in connection with the juvenile justice system. The company says that in rare cases, and only after a case review by community board-certified psychiatrists who are not employed by the Blues, reviewers may recommend that the juvenile justice system be involved as a complement to health programs.
"This may occur," the company writes in a fact sheet, "in the context of apparent criminal activity, such as when an adolescent may be engaged in the use of illicit drugs, underage drinking, auto theft, curfew violations, and truancy."
Blue Cross provides in its court documents detailed analyses of the review and decisions made in each of the six cases, showing when appeals were not taken and additional treatment days were not requested.
Missing from the court filing is a key policy issue raised by Blue Cross in its initial response to Mr. Hatch’s suit. At that time, the company said, "There is a larger issue at stake here. When employers or individuals buy health coverage from Blue Cross, they purchase a specific set of benefits. It’s easy to tell a health plan to pay for everything. The fact is that we can’t do that without taking something away from someone else. All of us — employers, consumers, government, and, yes, the attorney general — need to decide what we want from our health system and how we as a society should make difficult and expensive decisions. There are no villains here, despite Mr. Hatch’s efforts to manufacture one. Instead, there exists a legitimate policy debate about how the burden of medical care will be distributed within our society."
[Contact Mr. Hatch at (651) 296-3353 and Blue Cross and Blue Shield at (651) 662-2882.]
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