By Daily Mail (U.S.) | Created at 2024-12-16 22:26:46 | Updated at 2024-12-17 00:56:08
2 hours ago
Health insurance conglomerate UnitedHealth Group is engaged in a secret mission to cut company costs at the expense of thousands of children with autism, an investigation found.
Previously undisclosed internal documents obtained by ProPublica lay out a plan to limit coverage for the gold standard in therapy for children on the autism spectrum, many of them poor.
Costs to the company have ballooned in recent years alongside autism spectrum disorder diagnoses thanks to greater awareness and improved screening.
The cost-cutting initiative targets children enrolled through the company’s state-contracted Medicaid plans that serve the country’s poorest people, including 10,000 children with autism.
The specific therapy that internal documents target is applied behavior analysis, which the company itself admits is the ‘evidence-based gold standard treatment for those with medically necessary needs.’
Internal documents show that Optum, which manages mental health benefits for United, aims to ‘prevent new providers from joining the network’ and ‘terminate’ existing ones, even while acknowledging a national shortage of covered counselors.
The company is also mounting ‘rigorous’ clinical reviews to determine the medical necessity of each patient's therapy, which can lead to coverage denials.
UnitedHealth leadership is in the hot seat over a history of denying medically necessary treatments, an issue believed to have driven Luigi Mangione, 26, to allegedly assassinate one of the company's top executives.
Applied behavior analysis is a highly effective form of therapy for children on the autism spectrum that relies on positive reinforcement and repetition. But UnitedHealth's mental health arm Optum is increasingly denying coverage for this 'gold standard' therapy across the US
UnitedHealth's mental health division, Optum, aims to limit network expansion and 'terminate' existing providers, including those with higher costs, despite long wait times for qualified counselors due to limited coverage
Sharelle Menard’s son Benji was nonverbal for years, having been diagnosed with severe autism when he was three.
He was inconsolable as a baby and constantly frustrated because he couldn’t communicate with his mother or anyone else.
But after two years in applied behavior analysis treatment in their home state of Louisiana, murmurs became small words.
He made great strides with ABA therapy and requires around 33 hours per week to progress.
The downsides of insufficient therapy are considerable - from outbursts in school and toppled furniture to scratching classroom aides and being unable to learn.
Now, Mrs Menard is worried that Benji will regress after receiving word from Optum that it was refusing to cover the full number of hours that her son needs because he had been in therapy for an extended period already but was not making enough progress to graduate from it eventually.
The note from Optum said: ‘Your child still has a lot of difficulty with all autism-related needs. Your child still needs help, but it does not appear that your child will improve enough to end ABA.’
ProPublica’s analysis of internal documents found that the company is pursuing ‘market-specific action plans’ to limit children’s access to ABA.
While acknowledging that some areas of the country have ‘very long wait lists’ for ABA therapy, some of the ‘key opportunities’ laid out included ‘prevent[ing] new providers from joining the network,’ ‘terminat[ing]’ existing providers from the program.
Optum calculated that, in some states, the cuts to the provider network could affect over two-fifths of its ABA therapy groups in the network and up to 19 percent of patients.
Internal documents from Optum show its strategy for identifying ABA therapy providers it could justifiably kick out of its network if the costs are deemed unusually high compared to other providers covered by the network
Internal documents reveal that Optum has been scrutinizing ABA providers closely based on invoices and the number of patients they serve.
Aspire and providers like it can be flagged for common patterns in ABA therapy, including billing on weekends or holidays, treating multiple family members in one session, having long clinician or patient days, delivering more services than average, or suddenly increasing or decreasing patient numbers or claims.
Optum has repeatedly challenged claims from Aspire.
Benji had progressed Immensely by the time he turned seven. His aggressive tantrums had become less frequent, so leaving the house was finally doable. He could also speak a few dozen words.
Mrs Menard, a pool cleaner, decided it was time to enroll him in a special education program at school.
But when the insurance company decided not to cover the cost, Benji regressed with diminished treatment hours.
He snapped a swing in gym class, couldn’t sit still, and bit teachers when they tried to discipline him or give him instructions. Eventually, his speech regressed as well.
Mrs Menard said: ‘This motivation and momentum — when you lose that, it’s so hard to get it back.
‘There’s nothing else that I’ve known to work.’
She had to withdraw her son from school and enroll him in a home-study program managed by his therapy group, which costs around $10,000 per year in addition to his therapy costs, some of which are still covered by insurance.
Benji’s doctors wanted to increase his therapy hours from 24 to 33 per week. They expected the insurer to approve the request, as it was less than what had been covered previously and only nine hours more than what was currently authorized.
But Optum denied the request in May, telling Mrs Menard and Benji’s therapists: ‘Your child has been in ABA for six years.
‘After six years, more progress would be expected.’
Joslyn McCoy, the founder of Aspire, is no stranger to denials of care from Optum. She has continued to provide necessary therapy hours to children even without being reimbursed by the insurance company
Optum, manages mental health benefits for UnitedHealth Group. It's a major driver of the company's profits with the latest estimates putting revenue at around $64 billion this quarter
One of Benji’s therapists and the clinical director of the therapy program, Aspire, Whitney Newton, was outraged at the company’s denial. It wasn’t rooted in established medical standards for the treatment.
She said: ‘We know what he needs. It’s in our scope of practice and it’s our right as the provider to determine that.
‘They’re cutting and denying an unethical amount.’
By law, health insurers must cover mental health treatments to the same extent that they do physical maladies.
A previous ProPublica investigation revealed how United has run afoul of the mental health parity law by selectively applying a proprietary algorithm that assesses the medical necessity of mental health treatments, particularly for ABA.
It was designed to automatically evaluate whether certain therapies were justified based on predefined criteria.
This led to many denials of coverage for therapies deemed ‘excessive’ or ‘not medically necessary,’ even when clinicians supported them as essential for patient progress.
Even though Optum denied coverage for Benji’s necessary treatment hours, his therapists have continued to provide it.
A state administrative judge will decide on an appeal next month for the additional hours that Benji needs. If approved, Benji’s therapists will be paid for the six months of services they’ve provided without the insurance company reimbursing them.
Even if the appeal is successful, the therapists must start over with their dispute with Optum. Each insurance authorization lasts for about six months.
So soon after the hearing date, Benji’s therapists will have to request coverage for his treatment all over again.
Joslyn McCoy, the founder of Aspire, said: ‘We don’t think it would be safe for him to do what the insurance is saying.’
