Ok here we have some additional Killer Algorithms at work with the health plans of government employees and those enrolled in Healthy Families being denied. HMOs and health insurers are supposed to provide coverage for children by certified professionals, and they do not need a state license.
OK so here comes the interpretation with the analytics business models at work, the public employee healthcare was not included so analytics said, save money. There are no state licenses for ABA therapists…all about context again to save some dollars. So set the parameters to “deny” so the machines can automatically process the claim according to the verbiage with not finding a license listing, there’s the algorithms at work. This case was won by the Consumer Watch Dog.
The original law was passed in 2011 as insurers were denying care right and left for autistic children and the Department of Managed Care stuck to their guns it appears and were still wanting a license…so they let all the claims get denied and offered no assistance in settling the matter. What lawyer found this fine line one has to wonder advising the Department of Managed Care to hold tight with requiring a license, either that or someone didn’t do some research to find out there is no state license..duh on this one. BD
SANTA MONICA, Calif., Sept. 11, 2013 — /PRNewswire-USNewswire/ -- In a complex opinion issued yesterday, the California Court of Appeal ended the Department of Managed Health Care's (DMHC) discriminatory practice of allowing HMOs to deny treatment for autistic children of state employees and low-income families enrolled in the Healthy Families program on the basis that such treatment can only be administered through state-licensed providers.
The case was brought by the non-profit Consumer Watchdog and Strumwasser & Woocher LLP.
The treatment at issue, known as Applied Behavioral Analysis (ABA), has been found to be the most effective treatment for autistic children, as yesterday's opinion acknowledged. After the lawsuit was filed, the California Legislature agreed with Consumer Watchdog by passing a law in 2011 clarifying that HMOs and health insurers must provide coverage for ABA for children enrolled in private health insurance plans and that such treatment could be provided through providers who are certified by a national board, but not state-licensed. However, the Legislature did not include public employees and Healthy Families enrollees.
http://www.heraldonline.com/2013/09/11/5199124/court-of-appeal-rules-hmo-regulator.html
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