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The broken girl and a mother's war with UnitedHealth

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The toffee-skinned waif appeared beyond the glass partition, sucking her thumb as an escort toted her up the airport walkway. The woman had been charged with bringing the girl from an orphanage 7,000 miles away to a life of upper-middle class fabulousness in the suburbs of Minneapolis.

A crowd waited. Dad. Older brothers. Godmothers and grandparents. And Mom, so jammed with excitement that a defibrillator might be needed.

The 13-month-old had potting soil eyes and weighed just 13 pounds. To protect her privacy, we'll call her Allie.

"I just started crying," says her mom, Elaine, also a pseudonym. "My baby had come home."

Now, 15 years later, Elaine is still quick to tear up, but for very different reasons. Her fingernails show it; they're bitten to the quick. That's what happens when a parent's life becomes a meat grinder of crisis.

"It's been hell from the get-go," Elaine says as her eyes begin to rain from beneath her sunglasses. "I feel like I'm in a war, and it's battle to battle. I want her to have the happiest, healthiest, as independent of a life she can have. I think she just came to us broken."

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The baby

Mother's intuition said something was amiss.

Allie was a sickly baby. She was diagnosed with Nephrotic syndrome, a kidney disorder that caused her face and feet to swell. Steroids were administered. Bouts of pneumonia followed.

With her two older boys, Elaine had basked in the innocent curiosity of infants. A glint in their eyes showed an engagement with the world.

Allie looked at a different sky. An intense observer and shy to the point of withdrawal, the girl often retreated within.

"She would have a doll's expression," says Elaine. "It was when she was feeling unsafe. She'd disappear inside of herself."

Extended periods of funk were interposed by episodes of bionic anger. At a moment's notice and without explainable cause, she'd hurl her sippy cup, then scream for hours.

"You make up excuses for everything," Elaine says. "It was all the change. A new language. The steroids. We looked different. There was always something to explain it."

Neighborhood friends hosted a baby shower that first summer. Wrapped in her blanket, Allie was passed around a circle of women who cooed at her cherubic composure.

"Oh, look how cute and quiet she is," Elaine recalls one saying. But there was nothing in her eyes. "At that moment," Elaine says, "I turned to her two godmothers, and said, 'She's totally withdrawn. This isn't right.'"

What Allie had experienced in her first 13 months at the orphanage was anyone's guess. All the adoption agency said was her biological mother was very young, carrying the pregnancy to term in secrecy. The infant was taken away immediately.

Elaine had done her homework, studying up on attachment disorders. It's an umbrella definition, used to describe kids who struggle with love and trust due to some failure to forge the most crucial of human bonds. It can afflict young children who've been abused or have bounced between multiple caregivers.

Elaine tried to show her commitment by never leaving Allie with babysitters. Her best wasn't good enough. Allie wouldn't learn to speak until age three.

As she grew, diffidence and depression were bookended by flash storms of rage. Allie would regularly lash out at Mom. Dad, a marketing exec, often traveled for work.

Elaine started seeing a therapist, who explained away the troubling behaviors as tremors of big life transitions.

There were moments of dappled light.

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The yellow Disney princess dress was her favorite. Allie would "twirl around like a normal little girl" and insist on wearing it everywhere. In the frilly ball gown, crown, and shoes that were way too big, she was Belle from Beauty and the Beast.

"Those were the moments that I would hang on to," says Elaine, "because it showed there's this delightful little girl inside."

The girl

The delightful child rarely visited.

Allie's struggles brought collateral damage. Elaine and her husband divorced. Mom and the kids kept the home.

Then things started to go missing — lipstick, cameras, phones — only to be stashed in Allie's bedroom.

Adopted kids can have hoarding issues, said Elaine's therapist.

Allie's outbursts became more aggressive. She couldn't get a grip at school. She had no desire to make friends or participate in class.

She'd sit alone in a corner during reading time. Teachers thought she was a devout reader. The books were often upside down.

A psychologist suggested meds. Elaine was initially reticent. Prozac came first. Risperdal next, a drug prescribed to dull irritability for kids on the autism spectrum.

Allie's fracturing continued.

Insomnia became ritual. Early one morning she was found glued to the Playboy channel.

In first grade, Allie was diagnosed with precocious puberty. It's when a child's body begins changing into an adult's prematurely. The cause is unknown, although infections, hormone disorders, and brain abnormalities have been suspected.

Allie was seven years old when steroids again were piped into her system, this time to stifle her hurriedly developing body.

They worked, but stoked her mental struggles.

Allie had a developing porn fixation, according to her medical file. Elaine countered by hiding the remote, changing computer passwords, and nixing cable packages.

Allie responded with creativity. She'd record porn on a disc while using a family member's smart phone, says mom, then put it back so it looked like nothing was out of place.

As Allie continued to refuse engagement with the world, Elaine tried to do it for her.

In fourth grade she arranged a sleepover for her daughter. Allie spent the night at another girl's house.

"This is a little bit awkward," Elaine recalls the girl's mother saying on the phone the next day, "but [Allie] was up in the middle of the night and she stole a bunch of things. Would you mind checking her backpack?"

Elaine found lipstick and an iPod.

When confronted, Allie raged, trashing her bedroom and laying waste to the walls with marker. She also drew a picture. In it she was stabbing Elaine.

A psychiatrist's evaluation a year later yielded a grab bag of diagnoses, says Mom. Mood disorder. Depression. Social anxiety. And Asperger's Syndrome, a malady affecting the ability to socialize and communicate.

"That's when I was told it could also be reactive attachment disorder," says Elaine.

Take an attachment disorder, multiply it, and that's reactive attachment.

It can occur in kids who experience abuse, neglect, or separation from caregivers. It manifests in a variety of ways, like misguided readings of social situations.

Kids with the disorder presume loved ones will always leave, so they sabotage relationships in self-fulfilling prophecies.

There's neither a standard treatment nor much research beyond early childhood. But according to the Mayo Clinic, it "can continue for years and may have lifelong consequences."

The psychiatrist apologized to Elaine for the bad news.

"I'm like, 'Don't be sorry,'" she replied. "'Thank you for acknowledging something is going on!'"

At age 12 Allie took to purchasing thongs and sex toys online, says her mom, using one parent's credit card to buy while shipping the wares to the other's address. She was caught making sexually explicit videos of herself, according to medical records.

Therapy was supplemented with pharmaceuticals. At least a dozen had been prescribed by now. Nothing changed.

Allie's eruptions regularly included suicidal and homicidal threats.

During one, she declared her intent to hang herself, her medical records note. During another, she locked herself in a bathroom for three hours. Allie broke a mirror and threatened self-mutilation before her father knocked down the door.

At counseling sessions, Allie was so checked out her eyes were "rolling to the back of her head," says Elaine.

This isn't working, the therapist said. Allie needs more intensive help. The shrink told Elaine to establish a paper trail. When Allie turns violent, call the police.

"She pretty much told me the only way for [Allie] to get the help she needed was to involve the government," says Mom. "...I told her it seems crazy I have to create a police file on my daughter when I'm just trying to get her help."

After returning from her first day of high school, Allie told Elaine she was going to her bedroom to do homework.

"My first thought was, 'Huh?'" says Mom. "She's never done homework a day in her life."

Elaine checked up on her.

Allie had smuggled a backpack loaded with things she'd bought online then had shipped to her dad's house. Clothes. Magazines. Makeup.

"Daddy gave them to me!" she screamed when confronted, then came out swinging. Unable to land a blow, the teen threw a lamp. Elaine fled, hearing the sounds of her child tearing her bedroom apart.

Mom "just let her be," pondering her next move.

By nightfall, the house was quiet. Maybe Allie had fallen asleep.

"I couldn't believe the severity of the damage," Elaine says. "She had turned the water on and the basement was flooded. She'd punched holes in the drywall and ripped up these beautiful handmade portraits I had gotten done of all the kids. On the wall she wrote in magic marker, 'I'm going to kill myself. I'm going to kill my mom.' She'd taken a knife and stabbed it into the wall."

Mother and child exchanged no words on the drive to school the next morning.

Later that day, at an emergency meeting called with the therapist, Allie admitted she was still so angry with Elaine that she didn't think she could control her actions. She wanted to hurt herself, too.

Both admissions meant Allie was now an "imminent threat," the requisite threshold for placement in a psychiatric facility.

Twenty-four hours after her most violent episode to date, Allie lay on a bed at an inpatient facility.

The system

The legacy of the diminutive senator with the big roar lives.

Paul Wellstone, who died in an Eveleth plane crash in 2002, took up the cause of mental health nearly a quarter century ago.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires insurers to treat maladies of feelings and thought just like those of blood and bone.

But the insurance industry has never really followed this edict.

"What we're hearing from families dealing with insurance companies and mental health coverage is that the companies don't seem to understand the cost benefits of providing needed treatment upfront," says Scott Bryant-Comstock, founder of the Children's Mental Health Network, located in Durham, North Carolina. "The rhetoric of parity is there, but in reality, it's taking its lumps."

"Mental health is a bitch," adds former Minnesota Attorney General and Commerce Commissioner Mike Hatch. It's often subjective and speculative by nature, since science has yet to achieve a mastery of the mind.

For insurance companies, it's "the easiest one to turn down treatment," says Hatch, who's battled insurers on behalf of the state as well as in private practice. "It's easiest because you can't see the problem."

Which means nothing stands in the way of chronically denying claims.

Kathryn Trepinski, a California lawyer specializing in taking on insurers who deny claims, says "Carriers are resistant to providing mental health care treatment. It's expensive and, historically, they've not paid for it. ...Because a dollar that is not paid out in treatment is a dollar that's effectively profit for the insurance company, and that's what the company is interested in."

The battle for coverage typically works like this:

A child is admitted to a center. Within days, the insurer is on the phone, pressuring the facility to downgrade the patient from inpatient care — which costs upward of $1,200 daily — to a lower level of treatment.

According to the American Academy of Child & Adolescent Psychiatry, inpatient care should be considered for a child who has "already received services in a less restrictive setting and they have not been successful."

But if doctors refuse the insurer's plea, the carrier will often reject further payment or authorize just a few more days or weeks of coverage.

"We have these companies that get paid to provide mental health coverage, yet we let them off the hook," says state Sen. John Marty (DFL-Roseville). "...They have a lot of clout to have laws written in their favor and have administrative decisions made that go easy on them."

Becky Henry, founder of the HOPE Network, a Minneapolis group that helps people with eating disorders, goes a step further.

"They're breaking the law."

The denied

By the fall of 2013, Allie's stay in acute care began a season of multiplying chaos.

Despite Elaine's objections, the psychiatric facility transitioned her to an outpatient program four days later. The next day, her mom found a three-page suicide note.

Within weeks, police were called. Allie had transformed parts of the family home into the morning-after hotel scene from The Hangover, says mom.

She was hauled off to Fairview Riverside Hospital for a "mental health crisis," only to be discharged five days later.

"I was told that she didn't need to stay because she was no longer, in their opinion, a threat to herself or anyone else," says Elaine.

Allie took a teacher's iPhone during her second day back at school. That same week she ordered 20 pairs of thongs with her dad's credit card.

Elaine located a 35-day assessment program in Duluth willing to more fully examine her daughter.

Allie was found to be suffering from a "severe emotional disturbance" stemming from reactive attachment, mood, and social anxiety disorders. "Placement in a residential treatment is recommended," read the report.

Allie's insurance was provided through her father's employer in a plan administered by United Behavioral Health. In a follow-up email to Elaine, Allie's psychologist in Duluth said he had already been in contact with a United doctor: "...Sounds like they will support residential," it read.

Minnesota's facilities were full, but Elaine found one out of state that specialized in teens with reactive attachment disorder. Three weeks and 500 miles later, Allie was a patient.

After some initial pushback, Allie responded to counseling and to the facility's canine therapies, which use dogs as an example of unconditional love and trust.

Allie would later tell staff that her therapy dog is "the only thing/person/animal that she loves and... feels an emotional connection to," according to her medical file.

Despite the breakthrough, Elaine knew it didn't come cheap. As Allie entered her fourth month, the family received a letter. A United doctor in Houston said the company wouldn't cover in-house treatment.

In common insurance practice, the doctor neither examined nor talked to the girl. But he nonetheless wrote that the treatment "your son" is receiving "does not appear to be consistent with generally accepted standards of practice."

He justified the denial because Allie was no longer "at imminent risk of serious harm to self or others."

Elaine would soon discover the perils of placing her daughter in the hands of United.

The company

The glory days are upon UnitedHealth Group. The company, headquartered in Minnetonka, boasts "185,000 employees in 22 countries" while insuring or administering coverage to "100 million individuals worldwide" through its various subsidiaries and "strategic alliances."

United is Minnesota's largest public company, ranking 14th on the Fortune 500 list. Last year its profits topped $5.5 billion.

Since assuming the helm in 2006, CEO Stephen Hemsley has become one of the best compensated executives in the country. In 2010 alone, he took home $102 million, making him America's highest-paid CEO that year, according to Forbes.

But a growing choir of detractors say such fortunes are pumped by the company's practice of putting dollars before patients.

"I'm concerned they're one of the worst" for denying mental health coverage, says Senator Marty. "That's based on two things. One is reputation. I've heard stories for years from people who say they're not getting the kind of coverage they deserve from UnitedHealthcare. And two, the bottom line. Look at the money being made. You don't make those kinds of numbers without denying people the help they need."

Last year, UnitedHealth and its subsidiaries were hit with a class action suit in California, charging the company with ignoring guidelines from respected guilds like the American Academy of Child & Adolescent Psychiatry. Customers claim that if a child isn't an immediate safety threat, the company chronically denies or shortchanges coverage, even when severe mental illness obviously persists.

"It pays for them to deny claims because... those claims that are denied aren't subject to any kind of penalty except the payment of the benefit," says Meiram Bendat, one of the lawyers bringing the suit. "They can get away with it because there's been virtually no enforcement of mental health parity laws.... What makes United particularly offensive is they seem to ration care at every level."

Nicole Quigley, a spokeswoman for Crowell & Moring, the law firm defending United, would only say that "the firm has no comment."

Back in Minnesota, the company faces equally vociferous critics.

Take the advisor to a Twin Cities mental health facility operator, who asked to remain anonymous due to business ties with United.

He says Optum, a United subsidiary that administers mental health services for Medica in Minnesota, "seems to us to be solely making mental health coverage decisions through financial considerations."

Within days of every admission, Optum is on the horn "pressuring us to discharge the patient when they're not ready to come home. Our medical staff is being pressured to violate their oath to do what's best for the patient."

Though Optum accounts for about 20 percent of his client's patient admissions, he says the staff spends 80 percent of its time fending off Optum's requests.

"HealthPartners, [BlueCross Blue Shield], they're good to work with because they seem to take patients' interests into account," he says. "For Optum, it's strictly a financial decision. The sooner a patient's level of care is downgraded — or better yet, they're discharged — the more money they make."

Not true, responds Glenn Andis, a vice president at Medica, which contracts with Optum to administer coverage. Nothing in the deal allows Optum to earn more by saving money through denials.

In addition to the federal Department of Labor, three state agencies are supposed to play watchdog over such problems, including the departments of Health, Human Services, and Commerce.

Yet the vast majority of mental health cases never reach regulators.

California lawyer Lisa Kantor, who represents people fighting denied mental health claims, says the system wears down a family's will.

Before the sick can approach government regulators, they've likely already lost up to three appeals within a carrier's in-house process, where the company serves as defendant, judge, and jury rolled into one.

If UnitedHealth has an explanation for the criticism, it's not forthcoming.

Spokeswoman Lynne High referred questions to Optum Director of Communications Lauren Mihajlov, who could not comment on specific cases due to privacy laws.

Though neither High nor Mihajlov responded to specific questions, Optum spokesman Brad Lotterman issued a statement saying his company's work with Medica in Minnesota meets protocol.

"Optum and Medica work tirelessly to ensure members receive the care they need to get and stay healthy," he writes. Contrary to the California suit's contention, Lotterman says Optum adheres to the guidelines of groups like the Substance Abuse and Mental Health Services Administration, the American Academy of Child and Adolescent Psychiatry, and the American Psychiatric Association.

"We understand that parents often have questions and concerns about their children's treatment options. We have worked closely with Medica to establish a process that enables members and parents to discuss their situation with us to better understand their options and if necessary, appeal treatment recommendations."

The cycle

The company's critics disagree.

"I hear more complaints about UnitedHeathcare and Optum," says former Attorney General Hatch. "They seem to have a higher ratio of complaints than any of the others."

Eating-disorders specialist Becky Henry started hearing complaints about United's denials nearly a decade ago. "The numbers have only multiplied over time," she says.

Take the case of a Wisconsin woman, whose mother asked that she not be identified to protect her privacy.

Her daughter had always possessed suspicious eating habits. She'd only eat pineapple for a week or appeared to be surviving for days on Gatorade alone.

During her first year away at college, she came clean: She was a full-blown bulimic.

Her dad provided insurance through work, which was administered by United Behavioral Health.

For more than three years, the daughter hopscotched from inpatient treatment to outpatient programs. United would sign off for in-house care. But as soon as her body mass index stabilized, the company would downgrade the level of treatment.

"What [UnitedHealth] neglects to factor in is the physical symptoms of an eating disorder are only a part of it," says the young woman's mom. "Their brains are starved because they don't eat. Sure, you can put on a few pounds and the insurance company will say she's ready for a lower level of treatment, but that's a total lie.

"A week isn't enough time to effectively treat the mental illness that a person with an eating disorder has. Every time United denied our claims and she was instead put in [an outpatient program], it only fed the cycle and made a situation that was already a crisis for our family even worse."

In early 2013 the daughter entered yet another residential treatment center. Weeks later, UnitedHealth said it would no longer approve paying for inpatient care — over objections from her doctors.

"I did not agree then or now that [the patient] was appropriate for lower level of care at that time," wrote her psychiatrist.

In the past, when the young woman had been transitioned into outpatient treatment too soon, she'd regress and become suicidal, said her doctor.  

But it wasn't long before UnitedHealth also refused to cover outpatient care. A company doctor, who'd never examined the patient — let alone talked to her — went so far as to say that she was not committed to getting better.

"You do not appear to have medical or mental health concerns requiring this intensity of structure and monitoring," an associate medical director wrote the woman. "... You do not seem to be able to identify strengths and recovery goals and work with your treatment team on establishing a consistent treatment plan."

Her parents were forced to finance extended inpatient treatment themselves. Given enough time, healthy roots grew. The daughter now resides at a recovery home.

With the help of her father's employer, the family continues to battle United, attempting to recoup the out-of-pocket money.

At last tally, the family had burned through $150,000. They've recovered about $50,000 from United.

"United denies claims because they know you're in a delicate situation," says the mother. "They know you're scared. They know you don't have time to fight them and they know they can get away with it."

United continues to get away with denying coverage, according to Hatch, because state regulators lack "institutional will."

"The Department of Health and the Department of Commerce are pretty lax," he says. "I'm actually pretty stunned by their reluctance to get involved."

The mother

Allie spent 16 months at the residential treatment facility on the family's dime. Elaine's funds were almost exhausted. There would be no choice but to bring her home — unless United stepped up.

A therapist working with Allie wrote the company, urging it to understand the girl's condition.

"[Allie] has not demonstrated a capacity to function outside the benefit of intensive outpatient/day treatment," the therapist wrote. "To be clear, in no uncertain terms would [Allie] be functional enough to be treated in any level of care short of intensive outpatient/day treatment.... It is against treatment recommendation and medical advice for [her] to be prematurely discharged."

A United doctor in Michigan, who neither examined nor spoke with Allie, nonetheless denied the claim.

Elaine wonders what it would take for United execs to understand how their business practices only inflame families already living an emergency.

"I can only hope something in their personal lives gets them to experience what they put people through," she says. "I think it's abhorrent and shameful that they think it's more important to make as much money as possible than it is to provide the services people pay for. They're in the business of allowing people to suffer."

Allie came home four months ago. After family resources tapped out at $200,000, her parents can no longer afford inpatient care. After two appeals, United agreed to cover a month of Allie's inpatient stay, barely putting a dent in the tab, says Elaine.

"In a strange way, I feel like we're one of the lucky ones," Elaine says. "We have — had — the resources. What about the families who don't?"

There are signs that some of the cracks within the broken little girl have been spackled. Allie now wants to be around other people. She glowed the other night when her brother took her to a St. Paul Saints game.

But she's not where needs to be.

Allie recently stole an iPad and cash from a family acquaintance, says Mom. The porn habit hasn't gone away. She also cuts herself with staples or anything sharp she can find. Police have been thrice called to the house.

She spent five nights in a psych lockdown after an especially violent episode when she trashed the home and came at Elaine with punches.

Months have passed since that last incident. Elaine's face is still heavy with attrition.

"I'm a parent, right?" she says. "Our kids can blame you for certain phases of their development, struggles in their lives that they think you're responsible for. That's part of being a parent.... But it's much deeper than that for [Allie]. She's still suffering."