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20 October 2013 @ 04:19 am
Things to Know Before You Challenge Kaiser Permanente for Mental Health Care  
1. Know the process in California (review other states for any changes to this information).

A. File a complaint with Member Services. Do so in writing. Be clear and concise and it's great if you have evidence of your grievance. If your Kaiser therapist has already told you that more frequent therapy is not available, do NOT tell him or her that you are filing a complaint and do not discuss the complaint with your therapist. (I made this mistake only to end up with a very strained relationship as my previously sympathetic sounding therapist argued for Kaiser's policies.) If your therapist brings it up just say that you understand that they don't set policy for Kaiser and that your complaint is not about their performance at all. They will send an acknowledgment that will paraphrase your concerns. DO correct any mistakes in their understanding! They have thirty days unless waiting thirty days could endanger your life. In my case they did a quick review to see if they needed to expedite things.

B. Gather records from non-Kaiser sources if there is a history of your illness that supports your complaint. You will need to be ready to supply these in the next phase and you won't have much time.

C. When Kaiser turns you down, as they often do, you will need to prepare a request to the state for Independent Medical Review. The state itself does not make the decision. They have a company, Maximus, that conducts an independent investigation. Maximus has a staff with legal and medical experts that go over the records submitted to them. This is where your non-Kaiser records come into play. You'll be given a fax number to present these and they will be shared with Kaiser. The state will also talk to you to see if you need an expedited review and their process also normally takes 30 days.

In my case Maximus looked at a study that indicated that "passively suicidal" people can get by with just a monthly therapy appointment. I don't get how they read everything and determined that I was ONLY passively suicidal but there you have it. They also made the point that therapy hadn't "cured me" but failed to read the literature that indicates for some, long term therapy makes the difference between life and death.

I didn't have time to present evidence regarding former attempts or from outside treatment. I also didn't know I should present counter-studies and I didn't know the state, which had fined Kaiser 4 million dollars, wouldn't be deciding things. I thought I was writing my statement to a sympathetic audience rather than a rigidly impartial one.

2. If you have sources outside Kaiser that can help, ask them to search for studies that bolster your case. Look at the text of parity laws at the state and federal level.

3. If you have evidence that you tried to comply with Kaiser's treatment plan as best you could, provide it. Kaiser actually said I attended less group therapy sessions than I did.

4. This is a very stressful process for a person trying to cope with mental illness so it's best if you have a support system and a person who can screen these written decisions so you don't have to read them yourself. If you have access to legal aid, so much the better. Have a plan B if you don't win.

Ultimately I think it's good if more patients indicate that group therapy isn't working well for them. For those who enjoy group therapy, great. Nothing I've written is about making it unavailable as one option in mental health treatment at Kaiser or elsewhere. What I object to is a one size fits all treatment policy. We are individuals and we deserve an individualized plan that is not merely about which groups we should be referred to. EMDR, for instance, is now known to be highly effective for those with PTSD yet it was not offered to me either.

Good luck!
 
 
 
( 1 comment — Leave a comment )
(Anonymous) on July 24th, 2014 08:06 pm (UTC)
Thanks and...Prazosin for PTSD
Thanks for the helpful info! I just requested an IMR from DMHC & didn't know about Maximus. I do have a DMHC case number & contact person, so I am hopeful.

I was watching the VA suicide hearings on CSPAN. The MD parent of one of the suicides wondered why the VA hadn't considered prazosin for his son, since this drug has recently been shown to help with PTSD nightmares. It is an old blood pressure control drug, which has been around for a long time; not addictive, not a narcotic, not a psych drug, either. I learned about prazosin in med school, but it isn't used for blood pressure much any more. I was surprised that the Kaiser description of prazosin is totally missing any mention of PTSD uses. I doubt it is a magic bullet, but it seems neither Kaiser nor the VA have read the info available on new uses for this drug. Kaiser and the VA seem to be about the same in their treatment of patients.
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