The Riggs Blog

An Informed Response to the 60 Minutes Program, "Denied"

Senior Admission Coordinator at the Austen Riggs Center, Terry Owens-Gilbertby Terry Owens-Gilbert, Sr. Admissions Coordinator/Utilization Reviewer at the Austen Riggs Center 

I watched your segment on 12.14.2014 entitled "Denied" because I was interested in how coverage of chronically mentally ill patients by insurance providers would be presented. I am not a person suffering from mental illness or a parent or other family member of someone who does. I am a utilization reviewer for a not for profit hospital based continuum of psychiatric care, with most patients in residential treatment, and I am the first point of contact with the case manager once a patient has been admitted. 

My experience with insurance case managers has been enraging, frustrating, and bewildering. I am insulted by them, hung up on by them, lied to by them, and disregarded by them. I find their desire to get to NO, as fast as possible a cold hard fact. 

The patients at our organization are seriously ill, with long complicated histories of suicide attempts, multiple hospitalizations and failed treatments. The journey that has led them to us has been filled with short term stays in hospitals for medication stabilization, and outpatient programs that have not led to long term results. For most, it has been a vicious circle of crisis, stabilize, discharge, crisis, stabilize, discharge. When speaking to an insurance provider I am not usually given much opportunity to relate the entire history of the patient’s journey through their illness, the efforts they and their families have made to seek help, the failures and the setbacks. I am asked to report on the mental status of the patient at the time of the call. How are they today? Are they suicidal today? Are they a danger to themselves today? After as long as (on average) 90 minutes on the phone waiting to speak to a reviewer, I am usually told “Denied” in less than 15 minutes. This decision is made based on our brief conversation, the direction of which is steered by the insurance case manager. My attempts to interject history are usually shut down. When I express my dismay over the decision to deny treatment, I am quickly told the family is entitled to an appeal – today-in about an hour –with the patient’s therapist - who may or may not be available. When I try to negotiate for a few time choices I am told their doctors are on a schedule and cannot wait around for our doctors to make time for them. I have learned to ask what time zone they will be calling from after learning the hard way there could be as much as a 3 hour difference which, if not aware of, would lead to a denial because our doctor was not at her desk at 8 PM, as you so perfectly highlighted in your piece with Dr. Jack who made 3 calls, never spoke to anyone and denied the case in 54 minutes. 

As awful as this experience is for me, it is not the most difficult part of my job. That would be telling the patient and family members their insurance has denied coverage based on the patient’s mental status today. They are caring parents who are dealing with an exhausting illness while trying to keep their child alive.  They had hoped this time, after all the treatments that did not sustain their loved one, they would be allowed to stay in one place long enough and safe enough for treatment to take hold. Nancy West so eloquently described this experience in your segment when speaking of her daughter Katherine, who died at age 14, who was denied the coverage that Nancy knew and Katherine’s doctors and treatment team knew were medically necessary and stated this to the insurance providers over and over. We don’t know if the extended coverage would have made a difference, but what if it had? There could have been a different ending to this story.

If you are a CBS All Access subscriber, you can view the 60 Minutes episode here: http://www.cbs.com/shows/60_minutes/video/V0EAV25FWjaYdEKlbE8w2OgiQAxx8f_T/denied-inside-homs-mindfulness/

To hear Former Congressman Patrick Kennedy comment on the 60 Minutes episode referenced above, click here: http://www.cbsnews.com/videos/battle-for-mental-health-treatment-coverage/

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Comments

I have always considered myself fortunate that except in my very worst crises, I have been able to advocate for myself, including with insurance companies.  While I certainly never got anything approaching full coverage for my stay, I was able to convince them to permit paying for my actual sessions with Dr. Holiday with my allotted # of sessions, and then convinced them to convert some of my coverage for inpatient days (which they would not apply to AR) to coverage for sessions with Dr. Holiday.

It wasn't fair; it wasn't right; but it was something....

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