Anthem paid paid paid then denied and now...

[klimprecht]

What is the name of your state (only U.S. law)? CA

Anthem has paid and paid and paid our daughter's speech therapy. They started questioning and asking for "more info" last April. I sent a bunch of stuff to them and they denied our claim citing "Duplicate therapy" since she also receives speech therapy at school and they also said "Not medically necessary". I appealed and proved that by their own definition of duplicate therapy it was NOT duplicate. They denied our appeal not saying anything about duplicate therapy. They said it was because the provider did not include any therapeutic history or response to prior therapy and that while she did show improvement in receptive and expressive language, there were no progress reports. So, I sent progress reports and pointed to the therapeutic history AND response to prior therapy and then called and said "It's not the progress reports, it's that the therapy notes you sent were handwritten and they could not tell if I had written them myself or if the provider had written them. I offered to get another copy, this time signed by the therapist and was told it had nothing to do with that, but that the notes did not have her name on them and were handwritten and not typed on her letterhead. I told her that was a bunch of BS and she told me they were sending all previously paid claims back for reprocessing so they could ask for all the money back they had already paid because the diagnosis that was billed is not covered.

And, it should be noted that after waiting so long to receive word on the appeal (they promised 30 days, but it took nearly 2.5 months) I sent in other claims for fear that they would expire in case our denial was over turned. I wanted all claims at least listed in the system. I sent in June - Oct 2008. In Nov I received reimbursement for all 5 months. Then I was denied Nov 2008. And just this past Feb 2009, all paid claims have been "adjusted" to show negative payments and when I look on the claims screen online, they are simply not there. Not that they're there showing no payment, but they're not there at all as if I never filed and they never paid.

Here's the clincher. Our daughter has an expressive language disorder and I'm not sure where that falls medically. They said it is not covered for that diagnosis. As of 1/1/09, they extended covered for developmental delay from age 6 to age 19, so if they denied because of her age (now 10) she now qualifies under developmental delay, if that is even the reason they are denying coverage. If they could just say, "She has a developmental delay and that is not covered beyond age 6 for 2008, then at least we should get coverage for 2009 and beyond, but they wont tell me the actual reason for denial. I'm about to scream into the phone at them, but they wont tell me anything.

By the way, I hired an attorney. He wrote them a letter including reasons how they are out of compliance in CA. They are supposed to provide reasonable assistance, including but not limited to, telling me what documents to provide in order to provide proof of claim and they are also required to list ALL reasons for denial, not give me one reason and then keep changing their reasons.

Kathryn

[cbg]

Thank you for sharing your story. Since you already have an attorney, when you have a legal question, please share it with him as it would be inappropriate for us to second-guess him.

[klimprecht]

Oh sorry. I thought this was a forum for people to chat with others in the same situation. I didn't realize it was for legal advice, but now I can see that.

Thanks!
Kathryn

[lkc15507]

I do think the story has merit to be shared, but only if differing views may be shared. Without all medical detail as to your daugher's condition, I can only make general assumptions that may or may not be correct. From what you have posted, it does appear that the therapy may well have reached a maintenance stage that would not be considered an eligible expense by most health plans. You also mention the school involvement which is an animal that could be debated ad nauseum as to whether the school and / or private insurance pays. In general, the school should provide some service without the benefit of private insurance. We may not like that, but to argue it is a loser.

I only suggest that with regard to the private health insurance, you try to work with them. You must read and understand your coverage. You need to comply with the plan and submit materials, progress reports etc in order to achieve coverage. I do understand that your post indicates that you have tried to comply without success. I suspect that your lack of success is because the Plan considers the services to not be covered. Well within the rights of the Plan. However, you have nailed an item that few do. The apparent ambiguity of precisely why your plan denies the service. Medical necessity does need an explicit definition. I've never seen a plan that failed to define medical necessity, but not meeting the definition requires explanation. Based upon your post, I believe I know those reasons but the responses you posed do NOT adequately explain. Do your research, appeal. That is a must or you will likely get no where in court if you do not use the appeals process. All Pre-determinations, pre-certifications etc etc that result in an adverse determination require that EVERY (not just some or one) reason for the decision be explained. In a nutshell, the plan cannot change its mind and / or and to / change the reasons given in the adverse determination. Your post suggests that is what is happening. I suggest that depending on how hard you push this, you could likely "win" at some point based on that alone.

By the way, back to the beginning, given my knowledge of most typical health plan language, I do not think your child's therapy is or should be covered. I'm basing that on many assumptions, and althouth your info isn't complete, it gives me a good guess. Whether or not I agree is immaterial. What I have hoped to provide is a way to appeal and exercise your rights. Everyone is entitled to that process. Best to you, lkc15507