A newspaper notes that between 2019 and mid-2022, the insurance company that administers the medical care for many Georgia children denied or partially denied more than 6,500 applications for psychotherapy.
The Atlanta Journal-Constitution reports that many of the applications rejected by Amerigroup, a unit of insurance giant Elevance Health, involved children in state foster care.
Child advocates tell the newspaper that the Department of Community Health, which is tasked with overseeing the contract, is not holding Amerigroup accountable.
“The state is not doing its duty,” said Joe Sarra of the Georgia Advocacy Office, a federally mandated organization that advocates for people with disabilities.
In a January report to state lawmakers, the department said fewer than 100 psychotherapy requests were denied by state Medicaid managed care contractors, including Amerigroup, in calendar year 2019 and fiscal years 2021 and 2022.
But the newspaper found through documents obtained in open file applications that Amerigroup denied hundreds of psychiatric inpatient license applications, something the Department of Health and Human Services failed to include in its report to lawmakers. Amerigroup also rejected thousands of requests for assessments related to mental or behavioral health issues and hundreds of requests for autism-related services.
Melvin Lindsey, who runs Amerigroup in Georgia, has denied wrongdoing and told lawmakers in a hearing in January that children’s needs come before profit.
“I have never made a decision about how to treat anyone, especially a foster child, who has had to deal with expenses, and I never will,” Lindsey said. “We will always provide people with the right services at the right time.”
But Human Services Commissioner Candice Broce, who also heads her department’s Family and Children’s Services Division — the state’s foster care agency — was sharply critical. She urged changes as the Department of Community Health solicits new quotes for Medicaid’s managed-care contract, which covers foster children. Broce wrote in a 2022 letter that children wait weeks or months for an appointment, are denied services due to a narrow definition of “medical necessity,” and are deprived of care coordination for their complex needs.
“To our knowledge, DCH has never levied fines on Amerigroup for breach of contract terms,” Broce wrote.
In February, Health Department spokeswoman Fiona Roberts said the contracting process prevented the department from commenting on denials and access to care. She said the department will prioritize behavioral health on new contracts.
Roberts said his report was inconsistent with the Journal-Constitution’s coverage of denials because the newspaper looked at different categories and time frames. She said the department has never fined Amerigroup for non-compliance but has worked with Amerigroup to resolve issues.
E-mail correspondence and refusal letters from Amerigroup, obtained by Constitution magazine, show that Amerigroup has repeatedly denied services citing a lack of documentation the insurer wanted to prove medical necessity. Children who were aggressive, self-harming, or had other serious problems were often prevented from entering or staying in psychiatric residential facilities. The insurer would often reject such expensive stays with the same language of lack of medical necessity, often saying, “The records no longer show that you have these problems.”
Among the children denied access to inpatient treatment: an 11-year-old girl who smeared feces in a nursing home bathroom hours after being discharged from a psychiatric ward and attempted to jump out of a window. Amerigroup approved a home stay months later after the girl tried to both drown and electrocute herself, according to the state nursing agency. At this point, she would not take up any facility.
Amerigroup also denied a medical provider’s request for hospitalization of a 13-year-old foster child who attempted to harm himself and was aggressive toward others. While the state was appealing the company’s decision, she attempted to overdose on lithium pills and cut herself with glass.
The department assembled a team of attorneys to appeal denials of coverage, and Broce said in January the department has never lost an appeal. Meanwhile, Broce said the division advanced $57 million last year to cover treatment that Amerigroup refused.
“This is an issue that goes well beyond foster care,” said Melissa Carter, executive director of the Barton Child Law and Policy Center at Emory University.
“The fact is, many of the children who are currently in foster care might not need to be if parents had access to services to meet the needs of their children in the community.”
