Court ruling on insurance company denial of treatment for autism

In a preliminary ruling, Los Angeles County Superior Court Judge James C. Chalfant found that Kaiser Permanente's refusal to pay for a child's autism treatment because the provider was not licensed by the state runs counter to California's Mental Health Parity Act. That act requires insurers to cover care for mental and behavioral problems at the same levels they do for physical illnesses.

"A refusal to pay for . . . services based on the fact that the provider is not licensed is inconsistent with the intent of parity," Chalfant wrote in his Oct. 20 ruling.

The rest of the article can be found here.

Millions overcharged by health insurer

UnitedHealthGroup has agreed to a $50 million settlement after an investigation by the NY Attorney General's office pursuant to " hundreds of complaints about Oxford Insurance and its parent company UnitedHealthGroup" revealed that it "relied on Ingenix, a research firm owned by UnitedHealthGroup" to come up with reimbursement rates, according to MSNBC.

New York Attorney General Andrew Cuomo says Ingenix has been manipulating the numbers so insurance companies pay less. In a just-released report, he contends that Americans have been “under-reimbursed to the tune of at least hundreds of millions of dollars.” Although UnitedHealth Group and Oxford Insurance were the only entities investigated, other major insurers use Ingenix, including Aetna, CIGNA and WellPoint/Empire BlueCross BlueShield.

More insurers are under investigation.

Insurers Pressed to Pay More for Prostheses

A Wall Street Journal article forwarded by Meredith.

Many private health plans cap prosthesis coverage at $2,500 or $5,000 a year, or pay for just one device per limb in a lifetime, sometimes even for a growing child. The most basic devices can cost between $3,000 and $15,000, while mechanically advanced or computer-assisted models can cost up to $40,000.

Now, amputees and prosthetic-device makers are pushing state legislatures around the country to pass laws that mandate prosthesis coverage. The goal is to force private health plans to offer coverage comparable to that provided by Medicare, which pays at least 80% of the cost of prostheses and allows regular replacement of artificial limbs.
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So far eight states have passed laws which require coverage of prostheses which is comparable to Medicare. 27 other states are considering the same kind of legislation.

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The Amputee Coalition of America, an advocacy group backed by both prosthesis makers and individual amputees, has launched a campaign to introduce a bill in Congress. A big backer of the effort is Hanger Orthopedic Group Inc., the biggest player in the $2.5 billion U.S. prosthetics market. The coalition plans to enlist amputated Iraq war veterans -- many of whom have state-of-the-art prostheses through veterans' benefits -- to help make the case.
via Wall Street Journal Online

To read more about how the high cost of these devices affects families and people with disabilities, see the article. As one father of an amputee put it, you'd think they'd be willing to pay for an arm or a leg when you need one.

{Update: I found this story on CNN about a wounded Iraqi man whose wife is caring for him. He's unable to get prosthetic legs and she has to carry him . It highlights the lack of independence that mobility issues present. I'd like to add that there are people in our country as well who do without mobility equipment as well, behind closed doors and that when we read these stories, it's good to remember that rather than leaving it up to chance to solve one by one, we need to find solutions so that people can have the equipment they need.]

How a small mishap blacked out Florida

This morning authorities are probing how a small fire and a problem with a switch caused a blackout to happen that covered large areas of Florida. 

Yesterday, I just discovered Starbucks was closing for three hours nationally when I saw on the news that Florida was blacked out and thought "I like coffee, but isn't that a bit extreme?" Then I realized that Starbucks wasn't that powerful. 

Yet. Although they are promising customers perfection, i.e., if you don't get your beverage exactly the way you like it, they guarantee it will be fixed. Wow. If we could only spread that philosophy to social problems.

Imagine - your insurance claim is denied and you can call them up and actually negotiate and reason with them so that you feel satisfied that the product they sold you is actually worth something. Or you can negotiate the price and quality of your assistive device or- even better - your health care.  Or the access thereto.

Right now this perfection thing is only a policy at Starbucks, however. Not anywhere else. The rest of us have to settle whenever we're not in Starbucks drinking the beverage of our choice (if we can find a table we can fit at, but that's not covered in the perfection policy.)

For the people in Florida, I bet this morning they're just satisfied that  the lights are back on and they can see the beverage they'll be drinking this evening. 

Small mishaps. They really can lead to giant blackouts. Most of the time, however, it's not something you can see that obviously. 

Beating the odds

I was thinking about a conversation I had with a friend a few weeks ago. We were talking about wheelchairs. Her insurance company denied her claim for an ultralight wheelchair so she bought one on ebay. When it arrived, the tires went flat repeatedly. Turned out she had to take the tires off the rims, scrape them down (with the help of her father) and then they worked fine. There were a few other adjustments she made - on weekends and on week nights after her full time job. The job that provides the insurance that denied the wheelchair. The wheelchair she needs so she can go to the job.

Something in all of this just doesn't sound right to me. Her schedule sounded like: work, wheelchair repair, work, wheelchair adjustment, work - well you get the idea. This went on for a few weeks. And she said to me "No wonder people with disabilities don't work. This is discouraging."

The reality of insurance denials is harsh. Tiring, exhausting, expensive.

Sometimes the folks who perform public death-defying feats - trying to beat the odds -get the most attention. Like this guy. But every day there are lots of folks doing things - quietly - that defy the odds. Like my friend.

But of course there's no video of her soooo...

Getting the message across when you're in a jam

My printer/copier/etc. machine broke last week. I was thrilled to find that not only had the price of printers come way down (I don't need a laser printer), but I could find a much smaller one which was space saving.

So the printer arrives and Meredith comes over to set it up for me. When you're a quadriplegic and a box arrives, there it sits until someone takes it out and sets it up. Sort of teaches you delayed gratification. On the other hand, some would say it's nice not to have to do it yourself.

Meredith announces that she's set up so many printers that she doesn't need the written instructions. I know this is true because I've watched her set up various things before without ever consulting the instructions. This has included items like desks that came with instructions in languages that neither of us knew. In these cases she hands the instructions to me.

"Tell me what to do next," she says, grinning.

Okay so I was a comparative lit major for a few years and have a smattering of a number of languages. So I make things up. Put that screw there, that thing-a-ma-gig there. And it usually works.

This time the instructions were in English but we didn't bother. I watched as she took the tape off, plugged the printer in, put paper in the tray and then she said "Oh. Paper jam it says." Printers today have these screens that tell you what's wrong. It's almost as if you're just meeting a person and they give you feedback. "No, thank you, I don't like my coffee that way". Instead it's "Don't put the paper in that way".

And I'm sitting there thinking that the printer is text messaging us.

"Want me to check the instructions?" I asked.

"I can do it without instructions," she said, moving the paper around. The printer replied "Paper jam! Paper jam!"

Meanwhile I'm reading the instructions that say if you push the paper in too far, it will say paper jam. So I tell her this and she adjusts the paper and continues setting up the printer. I thank her and she says "Well I'm disappointed I needed the instructions."

Well in a way we didn't. The printer told us what was wrong, just not how to fix it.

For some reason it reminded me of our health care system. We all know it's broken, particularly those of us in the disability community. Over the weekend I spoke with three different people, all of whom have had claims denied through insurance for durable medical equipment. These are claims that used to be allowed a short time ago. All of these people have equipment that has "aged out" and is no longer able to be repaired. They all tell me they're trying to find other ways to replace these items - most have family members who can help. Some don't.

I can't help but feel that we're not getting the message out there loudly enough - that those of us with disabilities, in most cases, can't afford to buy these high priced items.

It feels as we're text messaging one way, however. We're sending out signals - and no one is responding. Perhaps it's because in our system no one wants to admit we need to go back to the instructions to get more information to fix what's wrong. Maybe it's from a lack of effort to address things that concern the disability community. Or maybe no one is bothering to listen to our message.

But we're definitely in a jam here.

Wheelchair - denied!

I'm worried about two of my friends. They're "Living in the Mobility Buying Options" Zone, otherwise known as LIMBO. No, not the Catholic kind of limbo - just a generic form of limbo. In abeyance.

Both had their claims for wheelchairs denied on their insurance so they're in this limbo of living with a wheelchair that has a limited future. One friend keeps adjusting her chair. I've told her that won't change the fact that it's falling apart. However, setting the chair up at different angles does change the ominous sounds coming from it. Instead of screeching, it simply squeals. Or it goes back to screeching when you readjust it. She convinces herself it sounds better every time.

"That's better," she says, getting back into it. "Don't you think?" Screech!

Another friend is in what I refer to as Total Equipment Denial, where she maintains that the screws falling off her old chair are- get this - from the weather.

"It's the heat," she recently me. "As soon as fall comes, the screws willl stay in."

"I don't know," I said, watching another screw fall off.

"It must be the humidity today," she replied, picking up the screw with a practiced movement and reaching for one of her screwdrivers which was somehow concealed underneath her jacket. "Or the barometric pressure."

It's never a good sign when you carry three screwdrivers with you because your chair needs so many repairs - and your insurance claim has been denied. It's a bad combo. Screwdriver in your left hand, insurance denial letter in your right. It's a sad sight.

LIMBO results in all kinds of bizarre behavior. One of these friends emailed me because she saw a wheelchair that's usually $4000 listed for $400. I calmly said it was a typo.

"No, it must be a deal!" she exclaimed. A half hour later she called me. "You were right. The guy laughed at me. And then he offered to sell me just the wheels."

He laughed because he doesn't understand the symptoms of LIMB0. People who suffer from it are desperate. They grab for any hope, any sign that maybe they'll be able to get a wheelchair without hocking themselves into debt for the next three years.

They do things like play Powerball. Spend their evenings going through ebay looking for someone who bought a new chair and just doesn't "like the color" (that does happen). And, in the end, somehow these people who live in the LIMBO zone manage to come up with a solution because, after all, they've been through it before.

That would be the last time their insurance claim on a wheelchair was denied.

Outdated US policies keep many people with disabilities from services they need

""Society must do more now before a crisis is upon us," Alan Jette, director of Boston University's Health and Disability Research Institute and head of the Institute of Medicine panel, wrote in a report.

"Far too little progress has been made in the last two decades to prepare for the aging of the baby boom generation and to remove the obstacles that limit what too many people with physical and cognitive impairments can achieve," Jette added.

The report looked at a wide range of issues affecting the disabled such as accessibility of buildings and other places, gaps in public programs such as those paying for wheelchairs and scooters and health insurance coverage."

The report noted the growing number of disabled veterans as a result of the war and went on to say:

"Between 40 million and 50 million Americans -- roughly one in seven -- have some kind of disability, the report said. The number is expected to balloon over the next three decades as the baby boom generation ages.

"Inaction will lead to individual and societal costs -- avoidable dependency, diminished quality of life, increased stress on individuals and families, and lost productivity," the panel said in a statement."

Via Yahoo News

These are many of the issues which appear and re-appear in my advocacy work with people with disabilities - lack of quality of life, lack of access, barriers to obtaining necessary equipment and employment, stresses on caregivers/family/individuals, and gaps in public programs. If you're interested in reading more about any of these issues , please click on the tags below.

One thing I do disagree with is that a crisis is not pending-- it is already upon us, for those of us living with disabilities who are not receiving necessary services and equipment and employment....our quality of life is already lowered.

Insurance companies limit spinal cord treatment

Insurers are capping coverage on those with spinal cord injuries doing rehab despite medical advances showing that such rehab can lead to vast health improvements and a better quality of life.

You don't need that wheelchair....the (hidden) built in pre-existing condition clause

One by one, I've watched my friends being denied the wheelchairs they need to go to work by their insurance companies.

Instead, insurance companies offer them heavy, cheap alternatives which will make it difficult , if not impossible, for them to work full time, do their errands and get around. This is not just about whether the wheelchair is made of aluminum or titanium. One friend was told she was not eligible for a wheelchair under 30 pounds. Due to a birth defect, she has very short arms. I have no idea how she is supposed to propel herself to her full time job, mange around her house (where she lives alone), run her errands, etc. etc. in a chair that heavy.

So what's the point of having insurance for medical equipment if you do not get assistance with buying it? If they are going to deny us basic and necessary equipment, why should we pay premiums to insurance companies? It's like a built-in pre-existing condition clause that never goes away!

Of course, even if you are approved for a medical purchase, you still have to pay a per cent of the cost. So you're budgeting that in. When equipment is denied because in their view you don't need it (but you do), then you pay 100 per cent.

We could, of course, try using skateboards. It's cheaper and then we wouldn't have our finances tapped to the tune of thousands of dollars by paying for a wheelchair every few years. It certainly would be easier to push than those heavy wheelchairs.

I think perhaps that might make a nice visual at one's job, to show up on a skateboard and explain why. Of course, then you'd need an assistant to help you reach the file cabinets.