Blue Shield Improperly Denied Mental Health, Drug Treatment Claims, Suit Alleges
Blue Shield of California and its claims administrator wrongly restricted patients’ access to outpatient and residential mental health treatment, a class-action lawsuit says. The complaint comes from two parents who allege their teenage children were repeatedly denied coverage under their employer-based plans despite serious mental and substance abuse problems.
The suit contends that Blue Shield and Magellan Health Services of California, which handle the insurer’s mental health claims, developed criteria that violate accepted professional standards and the terms of the health plan itself.
For instance, according to the suit, patients were authorized for residential care only if less intensive treatment in the previous three months was unsuccessful. Such a “fail-first” approach is inconsistent with standards established by professional groups such as the American Psychiatric Association or the American Society of Addiction Medicine, the complaint says.
In an email, Blue Shield said “we disagree with the allegations in the lawsuit,” adding that the insurer would continue to “defend the case vigorously.” In court documents, Magellan has denied wrongdoing.
Another Blue Shield/Magellan guideline, pertaining to outpatient treatment for substance use disorders, denies coverage unless a patient demonstrates “motivation to manage symptoms or make behavioral change,” the suit states.
Yet “patients with substance use disorders are generally depressed and lack motivation, particularly in their early recovery, according to Meiram Bendat, president of Psych-Appeal, a Los Angeles advocacy law firm that is co-counsel in the case.
Source: californiahealthline.org Kaiser Health News
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