Insurers sanctioned for denying speech, occupational therapy payment

Anthem Blue Cross, Health Net and Blue Shield told to cease and desist denying benefit payment for speech, occupational therapy

A trio of California insurers--Anthem Blue Cross, Health Net and Blue Shield--received orders Monday to cease and desist from denying benefit payment for speech and/or occupational therapy services, according to an announcement by the state's Department of Managed Health Care.

Further, DMHC fined HealthNet $300,000 for "repeatedly and unlawfully mischaracterizing requests for services as coverage issues rather than medical necessity issues." The plans denied payment based on contractual exclusion rather than medical review.

These actions followed DMHC's receipt of 41 customer complaints against HealthNet, 24 against Anthem and 14 against Blue Shield. Among the members affected were children with developmental disabilities, expressive language disorders and speech delays.

One result of the insurers' payment policies was that children diagnosed with autism were denied coverage for speech therapy, according to an article in The Sacramento Bee. Parent activists have been some of the most vocal and visible opponents of the insurers' payment policies, the article said.

Most complaints that eventually reached DMHC first went through the payers' internal grievance processes, under which the insurers reaffirmed their original denials. This forced some customers to pay out-of-pocket for therapy received.

Yet according to the DMHC director Brent Barnhart, "medically necessary speech and occupational therapy are basic health care services that health plans must cover," and the imposed sanctions "will ensure that members receive the care required by law."

Insurer representatives told the Bee they're reviewing the orders. If they contest the accusations, the Office of Administrative Law will hold hearings. If the insurers lose, they'll have to pay members for denied benefits.

Controversy about whether speech therapy services to autistic children qualify for insurance coverage follows an influx of technological breakthroughs serving the same population: a new app may help increase socialization between autistic children and their peers, Kinect sensors may help diagnose autism earlier, and gaze-tracking glasses and facial analysis software may help detect problem behaviors.

To learn more:
- see the California Department of Managed Health Care announcement
- read The Sacramento Bee article

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