Pacific Shores Hospital vs UBH

My name is Lisa S. Kantor and I have been licensed to practice law in California since December 1983. I represent patients seeking mental health treatment and have unique experience and expertise with insurance companies who routinely deny benefits for patients who desperately require mental health treatment. 

I am writing in support of SB 999 (Cortese) which seeks to bar doctors not currently practicing addiction medicine from denying treatment which meets the criteria of the American Society of Addiction Medicine (ASAM). As of January 1, 2021, California law requires application of the ASAM criteria to determine length of stay and level of care in substance use treatment.

SB999 is necessary to hold insurance companies to the medical standards set by the State of California. Insurance companies are repeating improper claims handling practices despite litigation.

I would like to share an example which highlights the challenges facing mental health patients whose insurance claims are denied by unqualified medical reviewers. In 2010, I represented the interests of a mental health patient whose benefits for inpatient psychiatric treatment were denied by United Behavioral Health based on a denial by Dr. Barbara Center. Dr. Center is a psychiatrist and medical director of Prest & Associates, a medical review company hired by UBH and other insurance companies to conduct medical reviews of insurance claims. 

The trial court ruled in favor of UBH and I appealed to the Ninth Circuit Court of Appeals. The appeal panel found that UBH improperly denied benefits and abused its discretion in refusing to pay for treatment. The appeal panel found that the denial was based on “mischaracterizations of the plaintiff’s medical history and condition as presented by Dr. Center,” including “critical factual errors” that were “rubber stamped” by UBH. 

This was not an isolated review. Dr. Center has frequently appeared as a medical reviewer in mental health matters handled by my firm.

The mistakes of the past continue to be repeated by insurance companies with impunity. Dr. Center and her team of psychiatrists continue to conduct medical reviews for insurance companies regarding mental health treatment and substance use disorders. Well-established and reputable California treatment facilities such as Summit Estate Recovery Center (Saratoga) and AToN Centers (Escondido) report that Prest physicians deny 90-100% of all claims considered for review. 

SB 999 is focused on stopping unqualified doctors like Dr. Center and her team from denying treatment when it is mandated by the ASAM. Anthem California’s small group policies, which