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When
you sign up for health insurance your company
may have restrictions that do not show up on
your contract. You may not find out about these
restrictions until you get a denial notice. Then
it is too late.
Many
of you are probably insured by Care First Blue
Cross Blue Shield of Maryland. (BCBS) Did you
realize that BCBS does not feel that
psychotherapy is a useful treatment for AD/HD?
If you look at your policy, you may not see this
statement. I obtained a copy of the relevant
section of the BCBS Medical Reference Policy
Manual. This Manual is not routinely distributed
to beneficiaries.
“Medical treatment (e.g.
methylphenidate/Ritalin drug therapy) of
attention deficit disorder with or without
hyperactivity is considered medically
necessary.
“Psychological/neuropsychological
testing required to make a diagnosis of
attention deficit disorder is considered
medically necessary.
“Traditional psychotherapy is not
considered medically necessary for attention
deficit disorder itself, as no mental health
treatments have been proven effective for the
primary diagnosis of ADD/AD/HD, but may be
appropriate for secondary diagnosis, such as
depression or anxiety.”
A
nurse from BCBS who dealt with medical policy
said that a team of expert clinicians had
reviewed and approved their policy on AD/HD.
When I asked for the names of the experts, she
said that this was confidential. I have serious
doubts about any “expert” clinician would need
to keep his or her identity secret. If a
psychiatrist or psychologist really believes
that medication is the only effective treatment
for AD/HD why not say so publicly? Are they
afraid to defend their scientific opinions when
they see their peers at medical
meetings?
I
called the company for clarification of the term
“traditional psychotherapy.” It took me a couple
of weeks to get clarification. If I had not
asked my congressman intervene, I might still be
waiting for an answer. When I asked about the
long delay, they said that they had referred my
request to someone who was on vacation. The
representative from provider relations said that
BCBS would not cover any form of
psychotherapy—even behavioral therapy for AD/HD.
She described AD/HD as “incurable.” She said
that I should code for something that was
treatable, such as “impulsive behavior.” When I
asked for a specific separate code for
“impulsive behavior” she said that she was not
an expert in mental health.
Clarke Ross the CEO of CHADD National is
actively involved in this issue. I have been
very impressed with how rapidly he responded
when I contacted him. He is coordinating with
members of the CHADD Professional Advisory
Committee. He has also made contact with
representatives from the American Academy of
Child and Adolescent Psychiatry (AACAP) and the
American Academy of Pediatrics. The American
Psychiatric Association Managed Care Advocacy
Division has also expressed interest in the
issue. The AACAP is sending a letter
of concern.
Blue
Cross was originally founded by physicians who
wanted to make sure that their patients had
access to affordable health care. It was an
idealistic venture. Unfortunately, health care
and the insurance field has become big business.
BC/BS of Maryland, long a non-profit company, is
currently seeking permission to become a
profit-making company. I am concerned that once
it is beholden to stockholders, it will become
even less responsive to the needs of patients.
Stockholders are often after short–term profits.
They may be less concerned about long-term cost
savings related to preventative care.
Call
your state representatives. Let them know how
you feel about BC/BS’s position on AD/HD. Call
the office of the Maryland Insurance
Commissioner. Medication is important in the
treatment of AD/HD, but we need to have the
option of multimodal
interventions.
January
2002 Update: Care First Blue Cross/ Blue
Shield has reversed its position and will now
reimburse for psychotherapy for children and
adults with AD/HD. CHADD, the APA (American
Psychiatric Association) and AACAP (American
Academy of Child and Adolescent Psychiatry)
worked together with support from local
clinicians and state lawmakers to convince Blue
Cross to stop its discriminatory position toward
individuals with AD/HD. This is a victory for
consumers in the Maryland-D.C. area and shows
that we can make a difference if we work
together. | 
