Are private insurance companies denying mental health care to pass the buck to taxpayers?

(KMSP) - A growing number of Minnesotans with private insurance are turning to taxpayer-funded medical assistance for health care coverage.

One of them, Maureen Riverdahl, said she is currently living a nightmare.

"I'm exhausted. I don't think there's been a day that I haven't cried, even talking about this issue," Riverdahl said.

Her daughter Ireland’s autism and mental health challenges surfaced when she was in kindergarten.

Riverdahl's Blue Cross Blue Shield health insurance will not cover the treatment her daughter so desperately needs even though it had previously covered it.

DAUGHTER ATTACKS MOTHER

"[Ireland] does very well, but she has outbursts that cannot be managed," Riverdahl said. 

Ireland is now 15 years old and her doctors say she needs 24-hour supervision for her own safety and the safety of others.

"I have locks on my bedroom doors because I don't know if something's going to happen in the middle of the night, so I have to protect myself because I don't want to be ambushed," Riverdahl said.

Ireland spent three months in the hospital this past summer, where she assaulted a nurse and had to be restrained numerous times.

Just days before she was to transfer to a residential treatment center, Blue Cross Blue Shield declared it was not going to cover it.

The company's in-house experts reviewed Ireland's records and decided residential care was not "medically necessary". They said she is not "a clear and present danger" to herself and others.

"The hospital sent in over 500 pages of medical documentation and that's what they came up with," Riverdahl said.

So, Ireland came home to live with her mother, a single parent.

Riverdahl took six weeks of unpaid family leave from her federal job to be with her daughter around the clock.

"That's scary, it's incredibly scary to think that your whole life can be derailed by one decision," Riverdahl said.

But, she had something else to fear. Ireland's behavior was getting worse.

Riverdahl made a 911 call in September because her child was attacking her.

Ireland (on the phone): "I'm going to f***ing murder you."

Riverdahl: “No"

911 dispatcher: "Did she just say she wanted to murder you?

Riverdahl: "Yes."

911 Dispatcher:  Did she hit you again? (screams in background)

Riverdahl: Yes, and spitting and pushing me."

911 Dispatcher: "What is she so upset about?

Riverdahl: "I won't buy her a fish."

After that incident, Ireland went back to a hospital for a short time.

Riverdahl turned to Anoka County Social Services for help.

Ireland was placed in a shelter for juveniles, but she kept running away.

Police squad car video shows her in the back seat as she says to an officer, "Shoot me why don't you, ..gun." 

On another night, police found her in the woods. Ireland told officers she was a werewolf.

"Don't shine your lights on me," she said.

An officer tried to calm her down.

"I think you're a pretty special person, really, I do," he told Ireland.

He continued to tell her it is unsafe for her to be wandering around in the dark.

"Oh my gosh, if you were to get hit it would make me sad,” the officer said to Ireland as she sat in the back of a squad car.

But, Ireland responded: "I'd rather get hit."

MOTHER PLEADS WITH INSURANCE COMPANY

"I think it's unconscionable that the insurance company can deny treatment for something that is medically necessary," Riverdahl said.

The mother pleaded with Blue Cross to reconsider, but her appeal was denied.

Desperate, she turned to the government. Because of her disability, Ireland qualified for taxpayer-funded medical assistance which would cover residential treatment.

"This is what my insurance coverage is for, right? Why is it that everybody else in the state has to pick up the bill because the insurance company wants to make a profit?" Riverdahl said.

OTHER FAMILIES TURN TO MEDICAL ASSISTANCE DUE TO PRIVATE INSURANCE DENIAL

All this sounds familiar to attorney Tracy Reid.

At first, her private insurance paid for behavioral therapy for her son Max, who has autism. Then, it stopped covering it.

Reid's only option was to have Max placed on medical assistance. But because of her income, she had to kick in a monthly fee to the government.

Then taxpayers covered the rest of Max's treatment, which worked wonders.

"In three and a half years my son went from having an IQ in the 50s to having a totally normal IQ. He goes to regular school, he takes regular classes," Reid said.

The Fox 9 Investigators wanted to know how often public money is being used to pay for mental health residential care that's been denied by private insurance?  The state told them it does not track the numbers that way.

But the data show there has been an increase in the number of families with six figure incomes turning to medical assistance for some kind of help.

In 2014, there were 931 families with an income of more than $100,000.  There were one thousand in 2015.
Each of those families paid fees averaging between $500 and $4,000 a month to get a type of coverage through medical assistance which private insurance denied.

"I'm still appealing this because it's not the state's responsibility, it's the insurance company's at this point," Reid said.

Blue Cross and Blue Shield of Minnesota declined to be interviewed about Riverdahl's case.

The company also would not disclose how many customers have been denied coverage for psychiatric residential treatment.

“I’M SEEING IT ACROSS THE BOARD”

Elizabeth Wrobel is an attorney who has sued a variety of insurance companies for rejecting mental health care claims.

She has noticed a pattern in many of the denials.

"I think I'm actually seeing it across the board," said Wrobel. "They're not using qualified physicians on their end to analyze medical necessity."

In a statement to the Fox 9 Investigators, Blue Cross says it adheres to "all state requirements and standard practices regarding medical reviews."

In the Riverdahl case, the company said its experts made "appropriate coverage decisions based on what information was known at the time."

"Cost is the last consideration when determining the most appropriate treatment for mental health issues,” Blue Cross said in the statement.

“I don't trust them and the thought of having to deal with them again it makes me physically ill,” Riverdahl said.

Minnesota's Attorney General filed a lawsuit against Blue Cross 15 years ago accusing it of systematically denying mental health coverage and shifting the cost to taxpayers. The insurance giant did not admit any wrongdoing, but agreed to pay more than $8 million to settle the case.