>> >>: Between Grossmont hospital in la mesa and mesa vista hospital in Kearny Mesa, sharp
cares for more patients with psychiatric emergencies than any other local provider.
Sharp mesa vista has 7 different units including an ICU and an area for children and adolescence.
Psychiatrist Michael plopper is a medical directer.
He says over the last 20 years sharp has generally had good interactions with insurance companies.
Plopper says about two years ago, anthem changed the way it viewed claims.
>> >>: We now have more denied days from anthem blue cross than any other pair.
We have more hospital stays here that include denied days by the insurance company than
all of our other insurance companies combined.
>> >>: Plopper shared some denial letters from anthem.
In case after case anthem blue cross wouldn't pay for the initial hospitalization or a continued
stay because the company determined it was nt medically necessary.
Plopper says about half of his patients come in willingly with conditions ranging from
severe depression to schizophrenia.
He says the other half are admitted involuntarily.
>> >>: They're admitted against their will and those are the people who meet criteria
for 5150 or 72 hour hold and in that they represent an immediate danger to themselves,
to others, or they're so gravely disabled as a result of their mental illness they're
unable to care for themselves.
>> >>: Anthem has denied payment for 539 hospital days about one third of all daze submitted.
As a result he says an increasing number of sharp doctors are refusing to treat anthem
blue cross patients.
>> >>: We're down to very few physicians who will take these patients because the practices
are so futile they feel it's not worth it to them and they don't want to be in u position
of having a patient in the hospital they're having to say your stay is no longer covered.
>> >>: A similar situation at Carmel mountain ranch.
Medical directer tom Flannigan used to sit on one of anthem blue cross' committees.
He resigned two years ago when he noticed the insurer began to deny care for a high
number of his patients.
>> >>: I've been increasingly frustrated with the increasing arbitrary way that criteria
for patient care is applied.
I have had to send out patients that I've been very worried about and I lose sleep.
>> >>: The California department of managed health care regulates HMOs in the state.
Last year the agency sense sept a letter to all insurers, remindingÊ the letter spelled
ot the only conditions under which payment and care may be denied.
If the health plan reasonably determines that emergency services and care were never provided,
in cases where an y emergency provider conducted a screening examination and the enrollee should
have known an emergency did not exist, and for post stabilization services rendered without
prior authorization by a health plan.
DMLC officials said they haven't received complaints from San Diego providers and can't
comment.
But the California hospital association says it's heard lots of complaints and says the
law is crystal clear.
>> >>: The health plans must provide coverage and the treating physician, not someone on
a telephone, makes the determination of the emergency nature of the individual's illness.
>> >>: Anthem blue cross did not agree to be interviewed for this story.
In a written statement, spokesman Darryl ing said:
>> >>: When the clinical
information does not meet these criteria, the case is sent to a psychiatrist reviewer.
If benefits for the requested services are not sur certified after this review, anthem
has a former appeals process that the member can start.
>> >>: Sharp has recently appealed 366 hospitalization days that anthem wouldn't pay for.
The company reversed its decisions on only six of those days, a reversal rate of 1.6%.
The average reversal rate for all of sharp's insurers is 53.8%.
Dr.ÊTom flannigan says hospitals still provide emergency psychiatric care, even when insurance
won't cover it.
He says that care is limited, and patients are usually discharged pre maturely.
>> >>: They may not go home and kill themselves but they may not get their job back, well
enough to get back to their job, adolescents may not go to college when they are clearly
a candidate for college but because of their drug abuse or depression they never get to
college and that's the group that we never get to know about and it's very difficult
to measure.
But it's happening.