Blue Cross Blue Shield Violates Mental Health Parity… Again

This week and yesterday in particular, I experienced a sudden upsurge in eating disorder thoughts. Their abrupt appearance frightened me — why, if I am doing well, is this terrible illness still a part of me?

I made a plan to talk to my therapist later that night at treatment. Unfortunately, that never happened. Halfway through the day, my therapist called me to inform me that my insurance company, Empire Blue Cross Blue Shield, had denied any further treatment in the intensive outpatient program (IOP). The decision was going to a “doc to doc” session, in which the consulting psychiatrist at Blue Cross Blue Shield would speak with one of Monte Nido’s doctoral-level therapists. My whole body went cold then broke into a sweat. This can’t be happening. Not again.

I spent the rest of the day on the phone speaking alternately to my therapist and to case managers at Blue Cross Blue Shield. The first time I got through to a case manager named Tricia she seemed to not know precisely what I was talking about, and told me that she had no power over the situation — at this point, it was in the hands of the “docs.”

It took the Blue Cross Blue Shield doc all of 15 minutes to determine that it was no longer medically necessary for me to take part in IOP, thus I should move to a lower level of care. The anger, frustration, and injustice of the last ten months welled up in me as I realized that, yet again, some anonymous and indifferent representative at my insurance company was making a baseless decision about my healthcare. I decided to make one more phone call — and this time I would be prepared.

I researched what Blue Cross Blue Shield considered “medical necessity” for the IOP level of care, as well as the American Psychiatric Association’s guidelines. Armed with these, I called Tricia and said that I had one question for her: Why have I been dropped from this level of treatment when I meet the criteria for medical necessity as laid out by Blue Cross Blue Shield as well as the American Psychiatric Association? Every time I asked this question, she cited on fact: I had been at a stable weight for the last six weeks, which qualified me for strictly outpatient care. I pointed out to her several times that at the IOP level weight is not a criterion for medical necessity. If my weight were unstable or dangerously low, then I would not be at the IOP level — I would be at a higher level of care, such as partial hospitalization or residential.

Still not able to let go of the weight argument, she pointed out that if I were truly symptomatic, then this would be showing up on the scale in the form of weight loss. I reminded her that that is blatantly false. The National Institute of Mental Health confirms that some eating disorder patients maintain weights that are considered “healthy” despite symptom use. Weight is not a sufficient determination of eating disorder relapse or remission.

At this time, she also informed me that I am at “100% of [my] ideal body weight.” As any eating disorder treatment professional will endorse, disclosing information about weight is detrimental to an eating disorder patient. The fact that she made this statement makes me question her knowledge of eating disorders and her ability to make important healthcare decisions regarding my case in the first place.

Her next argument was that my treatment team should have reduced my treatment to three days per week a long time ago, but had instead “just let [me] stay” at four days per week. As a result, she said, there is no way to tell whether I do, in fact, need the IOP level, because I had not been given the opportunity to try fewer days and see how I fare. I questioned her logic, reminding her that my team and I had planned to reduce my days in treatment this very week in order to transition to outpatient soon. Even so, I also failed to see why dropping me completely from the program would be a reasonable way to test whether I would “regress further without specific IOP services.” If she wanted evidence, I offered she could review my treatment history: In June, I was dropped from a different IOP program rather suddenly. Within weeks I relapsed, which is what led to the new IOP admission.

Her final advice was to seek multiple outpatient groups. After all, she said, just because I’m not in a program does not mean that I need only seek help once or twice a week. I could find groups seven days per week if I so desired. I asked her to please help me understand the logistic and financial feasibility of finding seven different support groups to attend, and how that would be more productive than working consistently with a treatment team that could monitor my progress and design a course of treatment. No answer.

Blue Cross Blue Shield put my health at risk once before — I will not let it happen again. I’ve spent more than a decade suffering from an eating disorder, and I refuse to spend the next decade going in out and of treatment programs, a pinball bouncing between remission and relapse. I will do this once and I will do this right. I will take the advice of the trained professionals who are providing my treatment. I will cooperate with them and take the steps that are proven to reduce eating disorder symptoms and bring about full recovery. (And please note, Blue Cross Blue Shield, that that full cooperation and ardent motivation is also not reason to cut off my treatment prematurely, as has been the case in the past.) It will save us both a lot of time and money to do this right, rather than play bureaucratic and, frankly, dangerous games that involve my health and wellbeing.

I had one more question for Tricia, which I never got to ask because she was out of the office when I called today in anticipation of my second appeal. Happily, I was able to put it in a letter that I sent to Blue Cross Blue Shield as part of the appeals process (writing is literally the only way patients are allowed to communicate with them). If a cancer patient in your care was showing improvements from the chemotherapy and radiation treatments she was receiving, would you bar her from receiving the last few rounds just because she was doing well? Or would you listen to her doctor’s recommendations, which are based on both experience and proven research? If you answer yes to that question, and yet stand by the decisions stated above, then you are not adhering to mental health parity. And I will keep talking about this until I receive my rightful course of treatment.

So please tell me, Blue Cross Blue Shield: How are you going to provide me — the consumer of your service with very clear legal rights — the treatment I am entitled to?

Update:

The final appeal was supposed to happen at 3:30 today. The doctor never called my therapist. When she called BCBS to find out what was going on, they assigned a new doctor, because they other one was busy. This one took roughly five minutes for him to decide that I no longer needed IOP treatment. He didn’t even have my letter.

I feel helpless.

---

© The Middle Ground, 2014. Unauthorized use and/or duplication of this material without express and written permission from this blog’s author is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to the article’s author and The Middle Ground with appropriate and specific direction to the original content.