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).
Now the dogs have started a blog for telling patient care stories, the obvious reason for which is to counteract this blog and the thousands of horror stories that exist online. There is a submission form and everything, but they flat out state they are not interested in negative stories.
http://www.kaiserpermanentecarestories.org/tell-us-your-story/
I suggest that everyone who reads this should head over and submit their stories anyway.
Oh, this is going to be fuuuuuuun!
I can’t wait to tell them my patient ” care” story!
Beth
I’ll be sure and provide pictures too!
ok, i WROTE AND SUBMITED THIS “CARE STORY”. IT’S ALL TRUE….just a bit of editing to make it in context here
hmmmm…..been a member for over 25 years.
Just in the last eight or so:
1. I was sent home from the ER where the MD had failed to diagnose pulmonary emboli. very early the next morning my husband received a frantic call from a nurse demanding that he drive me back to the hospital immediately (apparently a radiologist had taken the time to read the scan?)I was in the hospital for 7 days. How I did not go home and die that night I will never be able to figure out.
2. a few months later I had a cardiac arrest in the cardiac cath lab, which resulted in total paralysis and a severe tremor of my right hand and a vegetative depressive state that lasted for over a year. The first month, it was so bad that I lost 15lbs from not eating. I eventually had to demand OT for my hand. Kaiser really stuck their neck out on this one—– I had 3 sessions authorized. So, I rehabed my own damn hand and it took about 3 years to restore full function. It’s still not quite what it was 7 years later. All the while, no offers for help from Kaiser. All I got was “well, we know you did not have a stroke so it will get better eventually”. Paralyzed right hand and vegetative mental state=inability to work for quite some time.
3. Four years ago, I was discharged from the ER twice in 2 days with active cholecystitis, finally requiring emergency surgery that very nearly ended up as a full-incision procedure because the organ(gallbladder) was so inflamed, about ready to burst.
4. Two years ago, I was in a motorcycle accident. It was pretty serious; a Harley vs. deer at about 50 mph. That night, I was discharged from ER with a fractured wrist that the MD failed to diagnose and a contuded chest wall and rib cage, the severity of which was dramatically minimized, despite the fact that she witnessed my difficulty breathing. I was not offered pain medication until I had been there for quite some time, and then it was a half of the usual dose given and I was not given more when it wore off. Upon discharge the MD prescribed Vicodin, take one every six hours and gave me 2 days off work. Clueless. My wrist was diagnosed on a follow-up visit 2 weeks later. The MD ordered the Xray, about which I did not hear for 3 days. I called ortho to set a time to get the wrist casted and the clerk attempted to give me an appt 2 weeks away. I raised hell. Then she offered 5 days away. I rose more hell. Then she said I could come in that afternoon. It’s like bargaining over the price of a car.
5. On many ocassions I have called the appt center first thing in the morning, only to be told that there are no appts anywhere withinin a 50 mile radius and that they will send a message and that I should expect a call back. I have never, ever, and I mean 100% here, received one of those calls back that they promise. At times this has forced me to the ER and a big co-pay, from my measly pocket in to your big fat one.
6. On more than one ocassion I have been given the wrong drug by the pharmacy. Rather recently, I was given someone else’s schedule II pills. The count was close to 300. I do not blame the pharmacy staff, I can see that the staffing is dangerously low there.
So I guess those are just some of my finer care stories at Kaiser Permanente, at least the ones I can think of right now. I have tried to get out on several ocassions but circumstances always seem to ruin that opportunity.
I know I have been a pretty darn expensive patient over the years with some health problems. I have to admit, as crazy as it sounds, that sometimes I experience little streaks of paranoia and wonder if Kaiser will at some point start “eliminating” some of their high cost users (if they haven’t done so already, that is, seems like they’ve come pretty close with me a couple times). You know, they’ll make you an appt at the clinic, you park your car in the lot, then come back out, get back in the car, put your key in the ignition…………KABOOM!!!
I was a Kaiser member for 30 years in northern and southern CA. In 2009 I was hit by a wealthy woman in Santa Rosa, CA. Kaiser proahibits the doctor from recording what he said in his office a year ago: “You need emergency surgery. You are at risk of spinal cord damage if you are in another car accident or fall. You incontinence is from the compression of nerves in your cervical spine.” Despite locating and giving doctors and the lawyers for both sides twelve years of images and tests, I cannot get a proper settlement as my injuries worsen. Kaiser
The number ONE reason Kaiser is having so many problems with failing to diagnose patients and neglecting their needs is from ONE thing: DISTRACTED NURSES and DOCTORS who hold their CELL PHONES in their hand, retrieving personal messages, checking breaking news, monitoring their Facebook page, etc….it’s a disgrace. KAISER should have in effect that ALL nurses and Doctors on duty shall NOT have their cell phones visible or in use at anytime when WORKING and getting PAID to help patients. GET THE HELL OFF YOUR CELL PHONEs. DO YOUR JOB. I was at an appointment where a Doctor, right in the middle of me telling him about my medical issues, stops, checks his cell phone, looks up, and goes, “Oh, Michael Jackson died.”
I’m trying to find legal help for arbitration with Kaiser. Have you found any?
To Eddie 1<
Kaisers policies and procedures do have a policy on NO electronic devices, cell phones, during pt care or, in patient care areas. Obviously no one is enforcing it. The only time it is enforced, is when they are trying to fire someone due to age, high wages, or reporting kaisers unlawful actions. Next time it happens, document person, time, date, and report it. Forget member services, they are useless. Only there to help employee. File with the state stating they are violating their own policies and procedures on electronic device use. I agree. Did you know that during all surgeries, the anesthesiologist is on his phone/pad entire time? Its disgusting/
I was turned away at the Sunset location, in the doctor’s office. This is after being informed by 2 Kaiser employees that counseling sessions were covered. Also, my school’s counseling office had been informed that I was eligible from my famil’s plan. But, when I show up at the Kaiser facility at my appointment, I was immediately asked to leave, Why? I was denied care, this is after they informed me I had these benefits as part of my plan! It was devastating to my life to not be able to receive care when I really needed it, and when I really needed it Kaiser denied it to me, despite it being a legal benefit owed to me!!