INTRODUCTION

SB 999 was written to out an end to a decade of yet another outrageous and harmful health insurance industry practice in California.  

SB 999 will ensure doctors are only performing within the scope of their license and are not being financially incentivized to deny authorization without the appropriate clinical backing of criteria established by the American Society of Addiction Medicine (ASAM), which became law in California on January 1, 2021.

SB 999 covers health insurance policies regulated by California’s Department of Managed Healthcare (DMHC) and Department of Insurance (DOI).   We will soon be headed for Washington DC as self-funded employer policies regulated by ERISA law, which is enforced by the US Department of Labor, suffer from the same harmful practices.  

1. THE CALIFORNIA SCORECARD.  Since November 1, 2021, fifty-one state-licensed California treatment facilities have been keeping score of the denials, and approvals, made by doctors sent by insurance companies, or working for insurance companies, to evaluate the request of an addiction doctor to extend days of treatment, or change the level of care.  On January 1, 2021 California mandated using ASAM criteria for addiction treatment, but the denial rates for many if not all doctors who do peer-to-peer reviews, or write the official denials, continue to be 90-100%.  

There are currently 17 doctors listed in the scorecards (their names are redacted for public consumption) deny or authorize. As stated above, many doctors refuse to disclose their full names and medical credentials. We are in the process of acquiring information about an additional 1-2 dozen doctors and will update the list as that information becomes available. 

2.  ANTHEM CA’s BROMANCE WITH PREST & ASSOCIATES by Dr. Kevin Murphy, Clinical Director of AToN Center in Encinitas.  Dr. Murphy takes a look at the practices of Anthem CA which sells most of California’s small group plans that offer an out-of-network benefit.  Anthem CA is apparently contracted with Prest & Associates of Wisconsin to provide peer-to-peer reviewers, none of whom are currently practicing addiction medicine.  Most are psychiatrists the major source of the prescription drug addicts treated by California treatment centers. He demonstrates that Anthem CA doctors rarely overturn Prest denials.  Other insurance companies, including Anthem national, overturn Prest denials more frequently.

3.  PACIFIC SHORES HOSPITAL v. UNITED BEHAVIORAL HEALTH - In California Attorney Lisa Kantor letter of support for SB 999, filed on the Legislative Portal, she describes a federal appellate court’s decision that found United Health Care had improperly denied benefits and abused its discretion in refusing to pay for treatment 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.  Dr. Barbara Center is Prest & Associates Medical Director.  She has a  95% denial rate on the California Scorecard.

4.  ANALYSIS OF 4 DENIALS by Prest & Associate doctors which were upheld by 

doctors from Anthem and Cigna, none of them specialized in addiction medicine.  

5. ANALYSIS OF 1 DENIAL handled by two Anthem doctors, one who volunteered that the peer-to-peer was being conducted to “determine payment” and in his written denial, although he had confirmed during the peer-to-peer that ASAM criteria would be used, he wrote that based his decision not on ASAM but on “a Medical Necessity definition from the Motive Technologies Anthem Classic PPO booklet.”

Dr. Stephen Mohaupt, an ASAM doctor who is also a California-based psychiatrist 

analyses misinterpretations of ASAM criteria.

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