A ProPublica investigation finds that health insurers are relying on an exclusive group of psychiatrists who are denying mental health coverage during reviews for coverage, even while court cases are being criticized or overturned in David-versus-Goliath battles.
One of those psychiatrists is Dr. Barbara Center, who was hired by the firm Prest & Associates, a firm that health insurers hire to review cases that are being appealed. She joined Prest & Associates as a reviewer in 2000 and within five years was promoted to chief medical officer of the company, according to her resume. She is licensed as a doctor in at least 20 states.
- In some of the cases under her review, she was present early in the treatment, and others as a final reviewer.
- Center’s recommendations were referenced in at least 12 lawsuits around the country that alleged insurers had wrongly denied insurance coverage to patients who needed intensive mental health care.
- Of those 12, 4 ended in favor of the insurer; 4 ended in settlement without the insurer admitting wrongdoing; one in partial judgment of insurer and patient; and 3 ended finding the insurer had wrongly denied coverage, but one was still settled following an appeal.
Many of the denials come in the middle of treatment bringing grave consequences. Some patients have relapsed back into substance abuse, become violent, or have died after prematurely being released from treatment facilities.
Another of Dr. Center’s cases surrounded a 43 year old woman with an eating disorder, severe depression and suicidal thoughts.
- Dr. Center wrote that the woman was not suicidal when, her medical records showed, she was actively planning to either overdose or starve herself to death. Dr. Center also incorrectly listed her weight, a key detail given her anorexia. And she undercounted the number of laxatives the woman was taking, saying she took 75 to 100 a day when the treatment notes repeatedly said 130.
- When an appeal to the woman’s case reached the 9th Circuit Court of Appeals, a judge found a ‘striking lack of care’ by three doctors involved in the case, including Dr. Center. But the lawyer representing the hospital in the case said that Dr. Center continued to be used by insurers when she assumed insurance companies would stop working with her.
In their rulings, judges have found that insurers, in part through their psychiatrists, have acted in ways that are “puzzling,” “disingenuous” and even “dishonest.” The companies have engaged in “selective readings” of the medical evidence, “shut their eyes” to medical opinions that opposed their conclusions and made “baseless arguments” in court. Doctors reviewing the same cases have even repeated nearly identical language in denial letters, casting “significant doubt” on whether they’re independent.
Some of those doctors have made critical errors, misquoting the very medical records of patients.
ProPublica reached out to six insurance companies that court records show have continued to rely on doctors who, judges found, wrongly recommended denying mental health coverage. The doctors aren’t named as parties in the lawsuits, but their decisions are included in complaints, exhibits and judgments. None of the insurers responded to questions about whether they take those repeated cases into account — by, say, refraining from using those doctors — or whether there’s a need for reform.