Ten Essentials, Mental Health, Patient Dumping

Shocking, Sad, and Strange – True Stories of Insurance Scams and Malfeasance

Patient Dumping of Psychiatric Patients

Homeless Woman with a CatRawson-Neal Psychiatric Hospital in Las Vegas, a state run hospital, is being sued in a class action suit led by the ACLU for “patient dumping”. They are accused of “dumping” over 1500 psychiatric patients. The accusation is that the staff would medicate or sedate indigent patients, give them a bag of sandwiches, and one days worth of meds and put them on a bus headed to California – Sacramento, Los Angeles, and San Francisco . Evidently this Nevada State public psychiatric hospital did not like the odds of reimbursement so they disposed of their patients.

The state web site says that Rawson-Neal: “Provides acute psychiatric inpatient treatment for adults with serious mental disorders. A multi-disciplinary assessment is the basis of each individual treatment plan. The hospital provides intensive and comprehensive treatment and after care recommendations.” The after care recommendations must read “Upon arrival in San Francisco walk to the Tenderloin district to locate a homeless shelter and soup kitchen. Good luck with your Schizophrenia and don’t come back to Vegas.”

When you gamble in Vegas you know the odds are in favor of the house. Casinos will evict you at will if they don’t want your business or they dislike your behavior. But we expect a lot more from health care professionals. Who would have thought that a public psychiatric hospital would treat ill people as disposable? The stigma of mental illness is enormous and sadly it can extend to health care workers. Are there any other categories of illness where people are treated so abysmally as those with mental illness? Can you imagine taking someone who needs dialysis down to the bus station and giving them a ticket to L.A. and a sandwich??

Fortunately with the ACA we have true parity of care for mental illness. But you have to get enrolled for the coverage. The expansion of Medicaid will help many of these patients if they can be reached, enrolled, and encouraged to seek treatment. Hopefully an effort will be made to enroll the most needy, vulnerable, homeless and ill citizens.

Ten Essential Benefits

The ACA defines certain categories of benefits as “Essential Health Benefits.” There are ten Essential Benefits in every policy:

Ambulatory patient services – this means outpatient care. Care at your doctor’s office or an outpatient surgical center. Just like now, different insurance carriers will have different networks. Make sure your doctor is in the network before changing your insurance coverage.

Emergency services – The purpose of the emergency room is for serious symptoms such as heart attack or serious and urgent conditions such as a broken leg. For non emergency but urgent conditions look for the nearest Urgent Care Clinic. They cost much less – sometimes just a copay. The wait is much shorter. I have never waited more than 20 mins at an Urgent Care Clinic. Food poisoning, a painful earache, a broken toe – I go to Urgent Care. If the medical staff thinks you need the ER they call for an ambulance quickly.

Hospitalization – You will pay some percentage of your hospitalization such as 20% or 30%. Check your out of pocket maximum to calculate your total exposure.

Maternity and newborn care – Prenatal care and Postnatal care is classified as preventive and is no cost. The law requires insurers to cover child birth and newborn infant care generally at the coinsurance rate. This is great for families – women and infants. For example in Texas none of the individual plans cover maternity. I spent hours trying to find a plan in Texas for my daughter in law which covered maternity. This will no longer be a problem. However there won’t be plans without maternity coverage so everyone is paying for this. If you are a fifty year old single male there will be maternity on your policy.

Mental health and substance abuse disorder services, including behavioral health treatment – every plan should offer mental health parity now. That means patients with a biological mental illness or mental disorder can have unlimited visits to their psychiatrist. Mental illness is treated as any other medical condition. If you have a brief medication management appointment than your cost might only be a copay. Therapy is covered generally at the coinsurance rate – 80% after deductible for example. The plans are intended to cover mental problems. It won’t cover couples counseling or life style coaches. For insurance to cover therapy you need some sort of diagnostic code of a psychiatric condition.

Prescription drugs – all plans must have prescription coverage which covers at least one drug in every class and category of medication. Most healthy people only use generics or an occasional brand name drug. However, just as now, if you have a serious chronic condition make sure your medications are covered on your plan. Also drug costs will be counted toward your out of pocket maximum. That is a good change.

Rehabilitative services and devices – Physical therapy, speech therapy, and cardiac therapy are examples of these services.

Laboratory services – A covered test ordered for Preventive Care is no cost to you. However a test ordered for diagnostic care will cost you, generally coinsurance. It is all about how your doctor or medical clinic code your service to the insurance company. A Colonoscopy coded as Preventive is paid at 100%. A Colonoscopy coded as diagnostic will apply to your deductible and coinsurance.

Preventive services and chronic disease management – The U.S. Preventive Services Task Force has a list of 50 services which are now covered at NO COST to you. This is a huge benefit for everyone. For detailed information see below:

Pediatric services, including oral and vision care – Under the law children under the age of 19 have dental care and vision care. Every insured child can have two dental cleanings plus other dental services.

See the full list of preventative care benefits provided to you by your insurance now at HealthCare.Gov.

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