Anthem Blue Cross of California: As cheap as it comes
On July 20, 2010 I reported on the nightmare we went through trying to get Anthem Blue Cross to pay for treatment of a client whose stay was fully authorized. Although we were ultimately successful, many executive hours were spent forcing Anthem to approve payment, cut and mail the check.
I was not as lucky getting reimbursement for another client who was treated in 2007-2008. The claim had been rejected repeatedly because we were not Medicare Providers. Of course not. Client is not on Medicare and alcohol and drug treatment is not even covered by Medicare.
Finally I called the office of State Senator Fran Pavley who represents Malibu in the California legislature. Her staff put me in touch with an Anthem lobbyist. She directed me to someone who waived the Medicare requirement. At that point, our alum who had paid for treatment in 2007-2008 was finally reimbursed for the benefit he had faithfully paid for month after month, year after year. Thank you Senator Pavley and your dedicated team.
So what about the 2010 clients who still needed their reimbursement?
By contrast with Blue Cross/Blue Shield of New York, Texas, New Jersey, Tennessee, Michigan. Washington, and several other states we know about, all of which have fair, even generous benefits for chemical dependency treatment, the standard Anthem Blue Cross of California coverage is worth less than $6,000. And you have to fight to get it.
Here are some examples:
Client John, a diagnosed schizophrenic, was on probation for having shot up his parent’s upper middle class neighborhood with a rifle while drunk. When he opened the front door and started tossing beer cans into the street, the terrified neighbors called the police.
Anthem refused to pay for his treatment. Why?
1) John can be “safely treated” in the community.
2) John does not have a severe medical disorder for which he needs constant supervision while receiving treatment.
This brilliant determination was made by two Anthem Medical Reviewers who our lawyer insists we cannot name. They definitely deserve to have a schizophrenic like John move in next door and drive past their children every day to attend a community outpatient program.
Client George is legally blind. He came in addicted to opiates and benzodiazapines. It took about 5 days to detox him from opiates, 30 days to get him off benzos. For most of treatment a counselor had to be at his side, to makes sure he did not fall down or walk into a wall. What did the wise Anthem doctors determine?
1) George can be “safely treated” in the community.
2) George does not have a severe medical disorder for which he needs constant supervision while receiving treatment.
Dear Anthem Doctors: George actually saved Anthem money by going to residential treatment. It would have cost Anthem much more to pay someone to drive George to and from outpatient treatment, and then remain at his side around the clock to make sure he did not slip and fall at home from the effects of getting off drugs. Even a Certified Nursing Assistant costs $20/hour.
Then we had a client we will call Sam. Addicted to speed balls (a combination of heroin and cocaine), on arrival he tested positive for opiates, methamphetamine, amphetamine and benzodiazapines. He reported having had hallucinations and hearing voices. He had an abcess in his right forearm which was filled with gauze. He could barely stand and complained of nausea. His terrified parents paid for treatment. We agreed to help them get reimbursement for the small amount of money their Anthem policy provided for chemical dependency treatment.
We called Anthem to get authorization for detox. Impossible though it seems, this part of his chemical dependency benefit was denied. We moved to Plan B: Residential Treatment (living at the center 24/7 and going to individual therapy, group therapy, family therapy, doing 12 Stepwork). Also denied. In the end, Anthem authorized 5 days of “Partial Hospitalization” (for which they pay even less than the pittance they allow for detox and residential treatment).
This means that the Anthem clinical team determined that Sam, though almost comotose and craving drugs, was perfectly able to live at home and commute to treatment each day. When I called back after 5 days, additional days of “Partial Hospitalization” were denied because Sam was still detoxing.
I heard an even worse story from the director of a treatment facility in Northern California. An Anthem client completed residential treatment and was stepped down to an outpatient program. Anthem refused to pay because they now knew the client had a “pre-existing condition.”