Dr. Scott Berger, the head of managed behavioral health services for Aetna Insurance in the Cincinnati area and elsewhere in Ohio, responded to the case of a suicidal 8-year-old girl by saying that “medical necessity is irrelevant” and that discontinuation of the little girl’s outpatient therapy benefits was “not Aetna’s problem.”
I called Dr. Berger on behalf of the little girl’s mother (for sake of confidentiality, I will not disclose the name of the mother or child). The mother had called a social service agency to find help. The mother told me that her daughter was “fixated on death” and had multiple mental health diagnoses, including bipolar disorder, obsessive-compulsive disorder, and possible schizophrenia. The little girl’s psychiatrist had written and called Aetna’s mental health provider, Human Affairs International, to ask for extension of benefits. The company declined.
On the mother’s behalf, I called approximately 12 different phone numbers within the Aetna system before reaching Dr. Berger. I explained to him the situation, and that I was aware of some managed care providers who would make special arrangements to continue outpatient therapy in the case of a patient who was suicidal. His exact words were, “medical necessity is irrelevant.” Startled by this, I reiterated the little girl’s story. Again, Dr. Berger said, “medical necessity is irrelevant.”
I explained to him that there are provisions in Sections 1742.04 and 1742.05 of the Ohio Revised Code which address continuity of services and not causing harm to an enrollee as part of what a managed care organization must prove to be licensed in this state. Dr. Berger said that he was aware of the law and that “it makes no difference in this case.”
After finishing with Dr. Berger, I called the national headquarters for Aetna in Hartford, CT. I shared not only his statements, but that I was prepared to go public with all of this. The national office contacted the state office, who then contacted Dr. Berger, who then called the mother and told her that I “misunderstood” him. For approximately three weeks, Dr. Berger and the mother talked about flexing benefits for the little girl, and the mother was pleased.
However, on August 20, I received a call from the mother saying that Dr. Berger had told her in their last phone conversation that there would be no flexing of benefits, and that once again the little girl’s outpatient therapy would not be covered. The mother told me that she had asked him over the preceding weeks to fax her written statements about the flexing of benefits but he never did. Now he’s telling her that she “misunderstood” him.
I think I understand him very clearly. I hear him saying that the life of a little girl is less important than his bottom line. I understand that through Dr. Berger, Human Affairs International and Aetna Insurance are saying they feel the same way. I think that attitude represents our worst nightmares about managed care coming true. I encourage anyone who thinks this attitude is wrong to contact the following people as soon as possible:
Dr. Scott Berger Leslie Lawson Ronald Compton Human Affairs Human Affairs Aetna Insurance P.O. Box 5012 100 N. Riverside Plaza 151 Farmington Road Richfield, OH 44286 Chicago, IL 60606 Hartford, CT 06156 phone: 800-424-4818 phone: 800-424-4204 phone: 860-273-3719 fax: 216-659-8052 fax: 312-441-3348 fax: 860-273-6872