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Oregon insurer agrees to $100,000 fine over autism claims denials

MGN

Providence Health Plan has agreed to pay the state of Oregon $100,000 in civil penalties over how it handled requests for health insurance coverage for treatment of autism in 2012, the state announced Thursday.

Autism patients, or their families, filed claims for a specific treatment for autism called Applied Behavior Analysis. According to the Oregon Department of Consumer and Business Services, the insurer denied their claims in such a way that wouldn’t allow them to appeal the denials to a third-party.

“At the time these claims were filed, there was still debate over whether ABA therapy was the most effective treatment for autistic patients,” said Laura Cali Robison, Oregon insurance commissioner and administrator of the DCBS Division of Financial Regulation. “We found that Providence Health Plan’s adjudication process at that time did not give consumers an opportunity to externally appeal payment or denial decisions.”

According to the state’s order, Providence denied the claims on the basis that the treatment was “experimental and investigational” but did so under its "Developmental Disability Exclusion (policy) rather than its Experimental Exclusion (policy)." That allowed the insurer to keep the patients from appealing to an independent review organization.

The state said that was in violation of Oregon law.

Paul Terdal, Oregon chapter policy chair of Autism Speaks, filed consumer complaints with the state and spearheaded the cases.

“While I applaud today’s action by the Division against Providence, I remain deeply concerned about the five-year delay in justice,” he wrote in a statement to KATU. “I call upon Insurance Commissioner Laura Cali and Department of Consumer and Business Services Director Patrick Allen to swiftly resolve all pending complaints over unlawful denials of treatment for autism, and ensure that the consumers are fairly compensated.”

In a statement to KATU, Gary Walker, spokesman for Providence Health & Services, said the insurer is happy things have been worked out.

“Providence Health Plan is covering applied behavioral analysis today, and has been since 2014,” he said. “It's important to note that this settlement involves claims back in 2012.”

Many experts say ABA therapy is the best way to help people with autism.

Related Coverage: Family 'ecstatic' after huge fines announced against insurers over autism coverage

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