At the end of February, the California Department of Managed Health Care (DMHC) issued a cease and desist order against Kaiser Foundation Health Plan, for denying physical, occupational and speech therapy to members with “non-physical conditions.” This action was in response to more than 100 complaints that were received by the department since 2009.
According to Anthony Manzanetti, chief of enforcement for the DMHC, “That means that people who may stutter or lisp or who have developmental delays don’t receive speech therapy.” Members with mental illnesses are also excluded.
The DMHC investigation found that Kaiser routinely denies coverage for these therapies on the basis that the enrollee does not have a physical condition, regardless of medical necessity. Denials such as this are in direct violation of the Knox-Keene Act and the state’s mental health parity law. In California, health plans are required to cover medically necessary basic health care services, including speech, physical, and occupational therapy. In addition, state law requires coverage for diagnosis and treatment for certain mental health conditions.
In the letters that are sent to patients, Kaiser cites its clinical practice guidelines as a reason for the denials, which state in part:
A service is NOT a physical or occupational therapy Health Care Service…when the therapy does not meet the indicators in these Guidelines. Some of the circumstances are described below: …Programs for communication / cognitive deficits from developmental disorders – where deficits do not impact overall health.” [Bolding, capitals and underline in original]
There is a similar section in KP’s guidelines for speech therapy.
Of course Kaiser denies it. Quoted in the San Jose Mercury News, a KP executive claimed to be surprised and disappointed by the DMHC action:
“The department appears to have misunderstood or mischaracterized Kaiser Permanente’s approach to providing speech, physical and occupational therapy to our members,” said John Nelson, Kaiser vice president, in a written statement.
“These therapies are not limited only to patients with physical conditions,” he said.
We don’t think so, Kaiser Executive. You’re just trying to put your organization’s typical Goebellesque spin on the matter, and it shows.
We have archived the full order here (PDF).