San Diego’s largest private providers of mental health services are having problems with California’s second biggest HMO.
These hospitals complain Anthem Blue Cross refuses to cover a high percentage of hospital stays for psychiatric emergencies.
Health care providers complain the situation is affecting access to care.
Sharp Mesa Vista Hospital in Kearny Mesa has seven different units, including an ICU, and an area for children and adolescents.
Psychiatrist Michael Plopper is the medical director. He says over the past 20 years, Sharp has generally had good interactions with insurance companies, including Anthem Blue Cross.
But Plopper said about two years ago, Anthem changed the way it reviewed claims.
"We now have more denied days from Anthem Blue Cross than any other payer," Dr. Plopper said. "We have more hospital stays here that include denied days by the insurance company, than all of our other insurance companies combined."
Plopper shared some denial letters from Anthem.
In case after case, Anthem Blue Cross either wouldn’t pay for the initial hospitalization, or a continued stay, because the company determined it wasn’t medically necessary.
Plopper emphasized he doesn’t hospitalize someone unless it’s medically necessary. He said about half of his patients come in willingly, with conditions ranging from severe depression to schizophrenia.
He said the other half are admitted involuntarily.
"They’re admitted against their will," Plopper explained. "And those would be people who meet the criteria for a 5150 or a 72-hour hold, in that they represent an immediate danger to themselves, an immediate danger to others, or, they’re so gravely disabled as a result of their mental illness, that they’re unable to care for themselves."
Plopper said since 2010, Anthem has denied payment for 539 hospital days, about one-third of all days submitted.
As a result, he said an increasing number of Sharp doctors are refusing to treat Anthem Blue Cross patients.
A similar situation is happening at Aurora, a psychiatric hospital in Carmel Mountain Ranch.
Medical director Tom Flanagan used to sit on one of Anthem Blue Cross’s medical advisory committees. But he resigned two years ago, when he noticed the insurer began to deny care for a high number of his patients.
"I’ve been increasingly frustrated with the increasingly arbitrary way that the criteria in patient care is applied," Dr. Flanagan lamented. "I’ve had to send out patients that I’ve been very worried about. I lose sleep."
The California Department of Managed Health Care regulates HMOs in the state. Last year, the agency sent a letter to all insurers. It reminded health plans of their obligations to cover emergency psychiatric care.
DMHC officials said they haven’t received complaints from San Diego providers, and can’t comment on specific denials of payment.
But the California Hospital Association says it’s heard lots of complaints, and says the law is crystal clear. Sheree Kruckenberg is CHA’s vice president of behavioral health.
"The health plans must provide coverage, and the treating physician, not someone on a telephone, makes the determination of the emergency nature of the individual’s illness," Kruckenberg said.
Anthem Blue Cross did not agree to be interviewed for this story. In a written statement, a spokesman said the company has a formal appeals process.
Sharp has recently appealed 366 hospitalization days that Anthem wouldn’t pay for. The company reversed its decisions on only six of those days, a reversal rate of 1.6 percent.
Sharp said the average reversal rate for all of its insurers is 53.8 percent.
Aurora’s Dr. Tom Flanagan said hospitals still provide emergency psychiatric care, even when insurance won’t cover it. But he said that care is limited, and patients are usually discharged prematurely.
"They may not go home and kill themselves or somebody else. But, they may not get their job back, they may not get well enough to even get back to their job," Flanagan explained. "Adolescents may not go to college, because of their drug abuse or depression. And that’s the group that we never get to know about, and it’s very difficult to measure. But it’s happening.”
Health officials say psychiatric illnesses are the leading cause of disability in people ages 15 to 44.
