Families complained to the Department of Managed Health Care, which submitted the disputes to independent medical review panels. These panels, composed of physicians working anonymously, review paperwork and issue individual, binding decisions.
Over the last two years, as the medical literature on the effectiveness of applied behavior analysis advanced, these independent review panels have decided every case in favor of the families seeking treatment. As a result, insurers, including Kaiser Permanente, were required to pay for the treatment.
Last year, however, Kaiser and other insurers, in letters and presentations to the department, urged it to change the way it handled such disputes and suggested that they no longer be sent first to the independent review panels.
The insurers began denying the treatment, saying it was educational -- not a covered medical service. And they suggested that the department, in deciding disputes, should first determine whether applied behavior analysis was a covered medical service. If not, then it should uphold the denials and stop sending the disputes to independent medical panels.
In March, the department issued a memo that adopted much of what the insurers had sought. The memo said the department would route autism treatment requests first to its coverage-dispute division.
In a statement, the department said it has told insurers they may not exclude any treatments "that have been determined to be healthcare services."
But the suit, filed Tuesday in Los Angeles County Superior Court, says the department's new policy has resulted in a reversal of outcomes. Insurers now are winning and families are losing. The decisions are binding and leave families to pay for the treatment themselves or have their children go without.
"Californians, including those stricken with autism and their parents and caregivers, expect regulators to enforce the law, not to side with insurance companies seeking to boost their profits by denying patients the care they need," said Harvey Rosenfield, founder of the nonprofit Consumer Watchdog and author of the landmark automobile insurance reform initiative Proposition 103.
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lisa.girion@latimes.com
