Care First Blue Cross Blue Shield of Maryland Denies Services to Individuals with AD/HD

The following article was published in Hypertalk, CHADD of Greater Baltimore magazine. It brings attention to fine print related to healthcare insurance. We are publishing the article with kind permission from Patricia Michel and Dr. Carol Watkins. Patricia Michel is on the National CHADD Board of Directors. Dr. Watkins is a member of Northern County Psychiatric Associates: Psychiatric Services For Children, Adolescents, Adults and Families, Baltimore, Maryland.

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 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 and the American Academy of Pediatrics. The American Psychiatric Association Managed Care Advocacy Division has also expressed interest in the issue.

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. BCBS 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 BCBS’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.