By Jesse Marx
By Chris Parker
By Jake Rossen
By Jesse Marx
By Michelle LeBow
By Alleen Brown
By Maggie LaMaack
By CP Staff
"This is like reliving a nightmare," says Kim, who asked that only her first name be used.
Inside the binder is the arsenal of files Kim built up over a year as she fought her insurance company, HealthPartners, to cover her son's treatment for chronic addiction.
Kim is an accountant; she deals with bureaucracy professionally. But in January 2010, when HealthPartners denied coverage for the second half of her son's 60-day treatment program, Kim found herself in unfamiliar territory.
By that point, her 22-year-old son had been in and out of rehab programs since he was 15. During his senior year of high school, his parents caught him with meth. In 2007 he tried a program at Hazelden. Nothing worked.
This new program seemed to be taking root when HealthPartners said that it would cover only the first 30 days. The second half was not, the company wrote, "medically necessary."
"You've got a child that has been so sick and so close to death, and you finally get them into treatment and they're doing okay, and then all of a sudden the insurance company says, 'We're not going to pay,'" Kim says. "So then as a parent you have a choice."
Kim and her husband decided to pay $12,000 out of pocket to keep their son in treatment. Between that money up front and their steep $10,000 deductible, HealthPartners covered only a tiny fraction of the $24,000 program.
The next month — after her son had completed treatment, entered a halfway house, and begun reconstructing his life — Kim woke up ready to act. She wrote the HealthPartners Board of Directors a letter saying that they should pay her claim, but again got denied.
In the denial, HealthPartners cited the American Society of Addiction Medicine criteria as their standards. But when Kim asked for more information, she got a letter saying that the company didn't have to give her any explanation.
"How am I supposed to prepare an appeal if I don't know what the standards are?" Kim remembers asking.
So she researched the guidelines herself, found the official manual, and called up its editor. He was the first person who could give her directions on how to proceed.
For the next four months, Kim pulled together all of her son's medical records from his five years of treatments, and paired them with the criteria in the ASAM manual. She found that HealthPartners' stated guidebook called for treating addictions like her son's with a program similar to the one he had been in.
When she was done, Kim sent in her nearly book-length packet to HealthPartners for her second appeal. She was denied the same day.
Kim ultimately won, but not before making her case in person at the HealthPartners Board of Appeals. She guesses that, by that point, she had devoted more than 200 hours over seven months to the process.
"Even in a state like Minnesota, which is one of the better states, Kim had to go through a million hoops," explains Nell Hurley of the Minnesota Recovery Connection. "Her son only got the care he needed because she was persistent and very well-equipped."
In a statement to City Pages, HealthPartners noted its support for the Wellstone Act, and cited efforts like its brand-new $36 million, 100-bed mental health facility at Regions Hospital as proof of its commitment.
Kim's son is now two years sober and a mechanical engineering student.
"If I hadn't had the skill, the time, the money to get for my son the treatment he was legally entitled to," Kim says, "I don't think he would be here today. I don't see how other people could do it. I think the insurance company expected it to be confusing and time-consuming enough to make us give up."
After Katie Bird sued UBH, they settled for a sum she can't disclose. But, she says, "I feel like we won."
Bird spent three months living at the Emily Program, treatment that totaled around $157,500 according to court documents. That doesn't include the cost of her two hospitalizations and the Intensive Day Program treatment she was in while fighting with UBH over whether she could enter residential care.
That's a heavy tab. But to Bird's lawyer, some of it could have been avoided by giving Bird the treatment she needed earlier.
"She was spending all of this time on the inappropriate level of care, and she could have spent that time in residential and probably avoided all of it," says Wrobel. "At the end of the day, they're trying to save money but it's probably more costly."
Bird also points to the unquantifiable victories, like the fact that she is now able to be a mom to her two children. "I never, ever, ever thought I would be able to live like I am now," Bird says.
To Dave Wellstone, experiences like hers are the reason to keep fighting.
"Everyone knows someone who is impacted by mental health," he says. "Those are the stories that keep you going. You don't have to look too far."
Opinions vary on when Washington might come out with some final regulations. Ramstad is on the optimistic end of the spectrum and hopes it can be accomplished in the coming weeks. Sue Abderholden hopes for next fall at the latest.