I have Kaiser. How to get them to accept/cover telehealth care?
January 9, 2019 8:16 PM   Subscribe

I have found a therapist service that offers sign language services; Kaiser will not seem to accept them as a referral and cover them, despite the service saying they had success with Kaiser in the past. How should I navigate this? More details inside.

I'm currently under Kaiser on their OPM plan, with a federal agency of sorts; open season won't be until November 2019, so cannot switch plans for the time being.

Using my workplace EAP's free six sessions, I was able to utilize therapy services with an online company that is deaf-founded. We use Telehealth to communicate via webcam. My six sessions went well, and I am interested in continuing services with them, given the convenience of being able to sign with them in my natural language and to be understood, especially being deaf.

I was told that after the EAP session, I would have to pay $100 per session, with a bit of room for negotiation. Even with the negotiated rate, that would still be too expensive for me, and I was told that some regional Kaisers were able to use them as a referral and then the client would pay only the outpatient, I think, co-pays through Kaiser (in my case, that'd be $20 per session, I believe).

I have talked to my PCP via their messaging system, explained my situation (being deaf, needing that unique service and with access, as their services would require interpreters, which might or might not help, and would be a challenge for me). My PCP has contacted the "head of Psychiatry" and was told that I had to go see them in person, that they seemingly did not support telehealth services. Wasn't very clear, though, and the "head of Psychiatry" did not contact me directly.

After talking with my therapist, I was given the recommendation to push back and try, as they had luck with other patients (perhaps in other regional areas, I do not know) getting Kaiser to cover their services (again, very specific - American Sign Language and access reasons).

Wrinkle: my PCP, after the contact, had left her position, so I currently have a new PCP (whom I haven't talked with or met yet).

So, how should I proceed? Am a bit lost and the Kaiser navigational system makes it confusing!
posted by dubious_dude to Health & Fitness (10 answers total)
I would contact the main Kaiser customer-service number (whatever's on your insurance card), rather than your PCP, for now. They may still tell you you'll need a referral from the PCP, but it sounds like this is more of a question about coverage, and so the insurance company is the one who'll have more information.
posted by lazuli at 8:46 PM on January 9, 2019 [1 favorite]

If your PCP already contacted Psychiatry then I would guess that there is a referral in the system. When someone I know (in Northern California) needed a similar referral, they called the Psychiatry department and got passed on to a clinician that specialized in doing triage. Based on their needs, the person was then able to get a referral to a non-Kaiser doctor.

Now, California is different - both because there are rules that insurance needs to cover telehealth and because they got sued for the very poor access to mental health services that they had been providing directly.

So I do suggest that you contact the psychiatry department and see what you can make happen. I agree with others that you should be very strong and clear about the fact that being able to communicate directly with your therapist in ASL would be substantially more effective than trying to work through an interpreter.
posted by metahawk at 9:42 PM on January 9, 2019

This is tough - I was hoping to find something in the ADA for you, but the focus is on access to interpreters, which I'm sure Kaiser would provide, not actually getting a therapist who will communicate in ASL directly.

I agree that this unfortunately puts you into the wheels of the Kaiser machine, which I've learned is not easy to manage. Try contacting the head of psychiatry directly and be really clear:
1. You need mental health services
2. Kaiser does not have any mental health practitioners that offer their services in ASL
3. You have found a services (tele therapy) that provides that and want to continue to see them
4. What are the steps that you need to do to get get a referral?

Don't ask "if" it's possible, ask "how" do I do this - because " of course" this is something they want to provide you.

You could also reach out to member services, but I worry you'd get caught in the bureaucratic machine, so maybe go there if Psychiatry says no. And last, if that doesn't work, go back to your new PCP and ask them.
posted by Toddles at 2:31 AM on January 10, 2019

A term that might help, too, is "continuity of care." Insurance companies (which Kaiser is) often have some leeway to grant exceptions for both access issues (like ASL) as well as continuity of care (the patient has an existing provider or treatment that's already working well for them).
posted by lazuli at 6:11 AM on January 10, 2019

Kaiser has escalation agents that may be able to assist, but you may need to go through your employer's HR to request one. Kaiser also has policies related to 'hardship,' i.e. if the services are available nowhere else, then it likely means that they will cover it, if your PCP makes the referral; however, the customer service agents often do not seem to be aware of this policy, which is why an escalation agent may help.

Another option is to contact your new PCP, because a lot of access to health care through Kaiser seems to revolve around the PCP referrals, and there may be someone in your PCP's office who can assist with the navigation and advocacy.
posted by Little Dawn at 7:40 AM on January 10, 2019

You may want to try and find out if there is anyone in network who is fluent in ASL already. If the answer is no, you have a better argument for them to cover the services to escalate . It is also likely that having someone fluent is cheaper than having to pay a therapist AND and translator per session which will work in your favor.

You should go see psychiatry in person once, just to be compliant to try and get the referral you need. I know it is a pain. Most likely they'll confirm you need someone fluent in ASL, stumble through an intake and give you the referral to the service that will provide you what you need.

Do contact the agnecy your trying to work with for guidance, they likely have someone who is knowledgeable in these single service contracts (not your therapist, likely someone in their building office) and who to contact to get them.

Good luck
posted by AlexiaSky at 7:56 AM on January 10, 2019 [2 favorites]

A follow-up question:

How would you recommend I contact the Psychiatry office and/or the head? I want to try avoiding going there in person if possible. I like the term “continuity of care”.

Thanks for the replies! :)
posted by dubious_dude at 8:59 AM on January 10, 2019 [1 favorite]

The disruption in "continuity of care" is an additional part of the "hardship" that may allow your therapist to engage in a "single case agreement" with Kaiser. Perhaps ask your therapist if they are willing to pursue the "single case agreement" and have your therapist follow up with the head of psychiatry - that is my understanding of how it may work, that the provider can contact Kaiser to set up a "single case agreement," explain the hardship that includes a disruption in continuity of care, i.e. no alternative services are available, and then Kaiser can cover the service as if it is in their network.
posted by Little Dawn at 12:18 PM on January 10, 2019

I would also contact the insurance company about coverage. They will be able to see if a referral has been put in and tell you the steps to take. You might also reach out to the telehealth therapy group again for their assistance. Basically getting this kind of thing done requires persistence and lots of phone calls, I'm sorry to say. I'm really glad you've found someone you like. Keep at it!
posted by purple_bird at 3:38 PM on January 10, 2019

While I am no expert, Kaiser has been pretty notorious for poor psychiatric services in California, note the previous reference here to a previous major lawsuit in California. If I remember correctly, Kaiser's approach is more oriented toward crisis intervention with the possibility of three follow up appointments. Once stabilized, the client is then shunted into group therapy settings. My understanding is it is very difficult to get one on one therapy sessions for any length of time if at all. Google Kaiser's issues with mental health services...
posted by WinstonJulia at 2:53 AM on January 19, 2019

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