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Originally Posted by InRealLife45
can I ask what insurance company you have? I went through a similar (not the same, though) fight for my T...she's gotten them to approve 2x a week sessions bc I'm chronically suicidal, and even then they always fight her on it, but they still approve it each time. Most recently she opted out of medicare so they terminated her contract and told me to get a new T, but I fought them and ultimately won 7 additional months of them still paying her (I think the bulk of next year up to June will be on me), but now I have the next 6 months to save up for it.
They CAN be fought. Have you tried legal aid, too? I got them involved (didn't end up needing them) but a lot of times just them knowing that you have a lawyer involved can light a fire under their butts.
Any chance you've been hospitalized at all lately for your suicidal thoughts? It really factors into them deciding to approve or deny your sessions.
What level of appeal are you at? State hearing?
Mine is still at level one (got 6 months out of it), but I think its bc I attended their board meeting and spoke directly to the CEO about it. Can you go to a board meeting?
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I have 3 insurances basically. The main is Medi-Cal (CA's Medicaid). I do not have MediCare. I then have Care1st for my managed care. And then, for therapy in San Diego, Optum is the managed care. Medi-Cal and Care1st are in support of long-term therapy. Optum is not.
So to continue with my T I will either have to pay out of pocket, pay for private insurance, or fight Optum. Right now, I'm fighting Optum.
Optum is being a pain in the ***. They aren't actually denying me yet. They are threatening and stalling approvals, so I can't actually go through the appeal process yet. I do have an advocate/legal aide already, but she can't do anything yet either. I contacted a senator, and she got me an obudsman on my case.
The problem isn't whether I qualify for long-term therapy. The problem is that no one can decide who pays for the bill. State or County? Medi-Cal or Optum? According to my Pdoc, I'm not the only one getting stuck in this debate.
But because I have contacted so many people and organizations, have completely researched and proven that there's a lack of mental health services in my area (especially any that fits my needs)... the head of Medi-Cal and the head of Optum are going to have a meeting, just those two, solely about my case.
Sometimes it's a good thing to annoy people. I do, however, feel sorry for all the staff at Optum who wound up getting contacted by all the state officials.
But I'm also happy I already put all the work into fighting them because I definitely don't have the strength to do it now.
I do have enough evidence (more than enough) to prove to the insurance I need therapy. But no, I haven't been hospitalized recently. I haven't been an inpatient for mental health for 14 yrs. I was at a crisis house about 6 months ago.