This story was originally published byProPublica.
There was a time when Sharelle Menard thought her son would never be able to speak.
The screaming, and screaming, and screaming, she said.
© Photo by Adam Berry/Getty Images
He would get so frustrated because he couldnt communicate.
After two years in treatment, his murmuring gave way to small words, with bubbles among the first.
But now, shes worried again.
So Optum is pursuing market-specific action plans to limit childrens access to the treatment, the reports said.
Key opportunities areoutlinedin bullets in the documents.
Optum has developed an approach to authorizing less units than requested, the records state.
Mental health and autism experts and advocates reviewed ProPublicas findings and expressed outrage over the companys strategy.
They have not answered questions emailed 11 days ago, citingthe Dec. 4 killing of UnitedHealthcares CEOas the reason.
Offered an additional day or two, the company would not agree to a deadline for comment.
Your child still has a lot of difficulty with all autism-related needs, Optum wrote.
Treatment may still be medically necessary even if its for skill maintenance or the prevention of regression.
Several advocates told ProPublica the companys strategy is legally questionable.
The federal mental health parity law requires insurers to provide thesame accessto mental health and physical care.
Itcontinues to usearbitrary and one-size-fits-all thresholds to scrutinize its therapy claims, ProPublica previously found.
But solving the problem by denying kids access to medically necessary care is a terrible solution.
What Happens if We Withdraw the Care?
Benji was making progress about three years ago.
The states Medicaid contractor, UnitedHealthcare, covered the bill.
Things a lot of people take for granted, said Menard.
While expertscontinue to debatewhich therapies are mosteffective and appropriatefor these kids, ABA is one of the mostwidely recommended.
It was time for him to go to school, she thought.
Menard enrolled him in their public school district, St. Martin Parish.
He attended Breaux Bridge Primary twice a week in a special education classroom and continued therapy the other days.
Menard urged the district to allow a therapeutic technician to shadow him in school, but it refused.
(The district declined to respond to ProPublicas questions, citing privacy restrictions.)
With the diminished hours of treatment, Benji grew increasingly disruptive.
It was a disaster, said Menard.
He snapped a swing in gym class and struggled to sit still during lessons.
When teachers tried to give him instructions, he hit them.
His speech plateaued and eventually regressed.
Menard, who cleans pools for a living, grew to fear the moment her phone rang.
School employees, unable to soothe Benjis tantrums, frequently called her to take him home.
He hadnt broken the skin, but after a dozen incidents, the situation was becoming unsalvageable.
Menard felt she had no choice but to withdraw Benji.
That was in addition to the therapy cost, which his insurance still covered.
But Optum denied the increase in a letter to Menard this past May.
Your child has been in ABA for six years, the insurer wrote.
After six years, more progress would be expected.
Shed seen firsthand how critical the therapy had been to his growth.
We know what he needs.
Its in our scope of practice and its our right as the provider to determine that, she said.
Theyre cutting and denying an unethical amount.
The centers founder, psychologist Joslyn McCoy, has grown accustomed to battling insurers.
After her team turned over thousands of pages of documentation, Optum conducted a separate in-person quality review.
But Optum has continued to challenge her patients individual therapy claims.
But the reward is contingent on him not hitting anyone for at least 10 minutes at a time.
At first, Benji lightly hit the staff, they said, as though testing the limits.
But when there was no response to his behavior, it began to escalate.
He tossed chairs and flipped tables.
He pushed Newton into a bookshelf, which collapsed to the ground.
He hit walls and windows, eventually turning his fists on his aide.
They stopped the experiment early, both for his safety and theirs.
Once they resumed the interventions, Benji was able to calm down.
She faxed it to Optum, asking the company to reconsider the denial.
The insurer did not change its decision.
Benji paused, rubbing the edge of his baseball cap and pursing his lips.
Sh, he said, stuck on the consonant.
Shoes, thats right, the technician responded.
She pulled out another card, showing a slice topped with white frosting.
No, Benji said.
she repeated, before adding, yes.
Yes, echoed Benji, but her correction appeared to frustrate him.
He hit the technician on the leg, softly but with determination.
Well let it go, she warned with a sugared voice, but hands to self, OK?
After 10 minutes, a timer beeped.
It was time for Benjis reward, getting to hear a reggaeton hit by Daddy Yankee.
Its a big reinforcer here, Newton said.
Even though Optum denied the additional hours of treatment, Benji has continued to receive them.
Were giving the hours even if they were not approved, McCoy said.
We dont think it would be safe for him to do what the insurance is saying.
Next month, a state administrative law judge will hear an appeal for the additional hours.
Even if that happens, their battle with the insurer will go back to square one.
ProPublica reached out to the state Medicaid programs with questions about their oversight of Uniteds practices.
(Read itsfull response.)
No other state Medicaid agencies responded to ProPublicas questions.
This motivation and momentum when you lose that, she said, its so hard to get it back.
She doesnt believe that Benji needs to be fixed or cured or changed from who he is.
Theres nothing else that Ive known to work, she said.
The patients cant afford it, she said, so eventually the private provider goes out of business.
McCoys center currently has a waitlist of about 260 children.
That list may likely expand.
The need is not going away.
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