Dear Dr. Anonymous:
Are you a Phil, Michelle or Darrell? Two years ago, you booted my seventeen-year-old son out of treatment, signing your denial letter “MD Psychiatrist.”
I understand that you were hired to qualify, or disqualify, patients based on a cost-benefit analysis. Your letter suggested that my son’s condition could be “managed at a lower level of care.”
The letter’s repeated use of “may” underlined the fact that you’d never met my son. The human being he is remained hidden behind a curtain of anonymity.
Allow me to open the curtain.
My son’s name, Iluka (“ee-LUKE-a”), is Australian for “by the sea.” Though he grew up in the American heartland, when he visits the coasts he snorkels through schools of fish as if he were one of them, his skin shimmering like the diamonds he dreamed of finding at age four.
In preschool, he hunted for hours every day for treasures to add to the diorama island he’d built in the bathtub. He used Play-Doh for land, twigs for tree trunks, leaves for palm fronds and sweet-gum tree balls for coconuts. Visitors received a tour of his “island museum,” a rapid-fire recital of details about the creatures inhabiting it. For months he added to that diorama, and we bathed in the other tub. He had no diagnosis then. Or for another four years.
If he suffered during the first eight years of his life, it was eclipsed by his creativity. Self-taught in drawing, in turning a sketch into a pattern and in transforming a pattern into a dress or shirt, he learned by trial and error, starting at three years old and graduating to online tutorials by middle school.
His interest in fashion started early. At seven, he read about the Titanic, then, with book open, studying ballgowns, he cut up socks and sewed them into mock-up dresses with buttons, sequins and fake gems.
“I’m figuring out how I can disguise myself as a woman,” he said, “and get on those lifeboats first.”
In reality, he struggles to keep himself afloat—but he tosses a life ring to others as if it’s second nature. In middle school, he befriended a girl the other kids ostracized. When the high-school art teacher yelled at a student with a learning disability, Iluka helped the boy. But he never asked his peers for help with math, or for a shoulder to cry on.
During middle school, his psychiatrist successfully weaned him off medication; he was thriving academically, and he enjoyed time with friends. He graduated from eighth grade, over 6 feet tall and headed to an honors high school.
I never imagined how hormones, stress and a pandemic could derail him.
By tenth grade, completing homework, reading, and leaving the house had become monumental, often impossible, tasks—even when he went back on medication. He picked at his skin, his weight dropped to 128 pounds, and he passed many days under his bedcovers, silent. When he did speak, he screamed about trying to find one reason to delay suicide. His psychiatrist, therapists and insurance provider considered his suicidal ideation and 15.8 BMI life-threatening: They agreed that he needed residential treatment.
His therapist recommended Rogers Behavioral Health, an adolescent residential OCD treatment center in Wisconsin. A five-hour drive and a five-hour intake interview later, the nurse said, “You have to say goodbye now. No family in the rooms.” She loaded Iluka’s suitcase, pillow and sketchpads onto a cart. Usually too cool for hugs, he held me tightly, our shirts wet with each other’s tears.
Every night he called me bawling, begging to come home. I promised that after this treatment the disorder would no longer control his life. After these calls, I’d curl up on the floor, hugging my giant dog and weeping into her back.
Ten days later, Iluka’s tears stopped. He began connecting with other residents. His team focused first on eliminating his excessively long bathing rituals, a success that remains two years later. He gained weight. He opened up to his team.
Dr. Anonymous, did you think these improvements indicated that he didn’t need to stay? Did the insurance company’s criteria take into account how easily a patient can slip backwards if suddenly ejected? Or that patients with severe OCD have multiple obsessions and compulsions to resolve before becoming functional?
Iluka’s psychiatrist at Rogers pointed to a complicated diagnosis: severe OCD with multiple subsets, ADHD, generalized anxiety disorder and depression. When the psychiatrist met with you for the final appeal, he was still in the process of adjusting Iluka’s medications.
I didn’t worry about denials; I had called the insurance company to check that my son could stay as long as needed. The woman on the phone said, “Generally, if we approve the first thirty days, we approve whatever the doctor requests.”
I assume that, like me, she didn’t know that my insurance provider was negotiating with another company to handle claims. On July 1, 2021, when Iluka was only a few weeks into treatment, the company you work for assumed control.
On July 8, at 4 pm, Rogers called me: The new insurance had booted Iluka out, denying the first two appeals. The staff at Rogers advised me to drive up on July 9 and be ready to retrieve Iluka, just in case his psychiatrist lost the final appeal, scheduled for that morning.
The phone call came on the road. Denied.
“Do you want to pay cash?” they asked.
It’s $1,000 a day. My entire monthly paycheck wouldn’t cover even a week.
So I picked Iluka up. When we returned home, I contacted every OCD therapist within sixty miles, only to be put on waiting lists or simply denied treatment, usually because his case was too severe. I did find a psychiatrist who prescribed five pharmaceuticals.
When a spot for outpatient therapy opened up in December, 2021, my son, by then self-medicating with prescriptions and street drugs, quit after a month. Instead of banging his head on floors, he started to shut down with pills, pot, shrooms and cocaine.
A year and a half later, he walked away from a scholarship at one of the top art schools in the world. Now he struggles to keep a job for more than two months. Smoking pot several times a day and suddenly quitting his medications every few months, he sleeps excessively, vomits regularly and cries daily.
Because I can work remotely, I offered him a move to Wisconsin for the Rogers outpatient program, assuming insurance would cover that.
He responded, “I can’t, Mom. The insurance company will approve it, then yank it away. You don’t understand: it was like surgery. Like they cut me open from collar to belly button. They started to operate, then sent me home without sewing me up. I trusted them. I shouldn’t have.”
This is what your denial has cost my son—and me.
Sincerely,
Miel Sloan
29 thoughts on “Letter to the Insurance Company Psychiatrist”
Miele and Iluka, I’m sorry health insurance (or the lack thereof) have hurt both of you so deeply. As a mental provider who had to quit due to severe OCD (plus other disorders) I have been on both sides of the coin. I have fought for my patients and I have despaired to not be denied as an inpatient myself. Iluka, I hope one day you will re-gain the trust to resume OCD treatment. I really admire your courage to undergo inpatient OCD treatment.
Thank you Miel, for calling attention to this burdening problem. Your story reminded me why I’m glad I am now retired. I loved working and providing needed care in a rural, remote community. When I entered medical school more than five decades ago, it was because I thought medicine was a service. All physicians families I knew were NOT on food stamps, and their children had shoes. While the appearance of Medicare appeared to help people in need, it quickly led to for-profit entities, whose owners and stock holders earn more than all primary care people, including physicians, nurses and other front line workers. I would not encourage my children or grandchildren to pursue medicine today, even though the need is great. I spent a lot of my time working with people with emotional and mental health challenges. My hope is that you and your son find the help he desperately needs, before it is too late.
Recently, my American son’s Mexican fiancé attending University here for post-grad work, became ill and needed surgery. She was referred to the hospital Emergency Department by the Primary Care provider because that practitioner was concerned that should the issue become more severe they would face malpractice claims. Despite having University issued health insurance, she was billed nearly $5,000 for the 5 hours of waiting in the ED where blood tests were done and little else. She had to pay $1000 out of pocket for the visit which did nothing but assure her that she was not critical. An ultrasound was recommended, but they would not order it there because if the criteria wasn’t met, the insurance company would not pay for it. She went back on an outpatient appointment the next day for it where the diagnosis was confirmed. (From my own experience, I had guessed correctly at the diagnosis.) After this experience, she telephoned her doctor in Mexico, got on the phone with him that day, having forwarded him the results of her tests, she was advised to have the surgery as soon as possible, given a recommended diet in the interim, and was encouraged to call back at any time if she needed additional help. She went back to Mexico a few weeks later during a scheduled school break, saw the doctor, got additional imaging tests, and had the surgery. She was cared for extremely well in the hospital there. Her doctor came daily and often twice daily to see her and with a post-operative complication, she stayed for 5 days. My son was bowled over at how attentive the care she received was and how easily she was able to contact the doctor when a need arose. She met with a dietician in the hospital and was given a daily diet plan for discharge along with zoom meetings scheduled for frequent follow up. She is still in weekly contact with this dietician who has been guiding her over the pitfalls of maintaining a safe diet without a gallbladder . The total cost of the surgery, hospital care, and everything was the equivalent of $5,000. The insurance she carries in Mexico picked up the majority of the cost. There, it seems, that the doctor still calls the shots and that the patient’s best interests are still respected. Having been through the chaotic and chopped up medical system here in the US for the same diagnosis, I can attest to the much lower quality of care here in a major US hospital. We are off our heads! The future for patients with chronic illnesses in this country is dire. I think this country is run by and for oligarchs while we condemn other countries for a backward system, we close our eyes to the unfairness and total disregard that is practiced here daily. Employees at our hospitals see this and are helpless to change it. Insurance companies are the oligarchs and we are their minions. Little wonder that medical debt has driven so many of us into financial ruin.
I’m honored to have been the journalist who wrote about Miel’s reading lo these many months. Still in draft form at the time, the essay Miel read that night, which she revised and posted here, was no less compelling.
I am so sorry that you and your son have gone through- and are still going through – this. It’s so painful when we cannot help our children and when the resources that can help them are denied. He is fortunate to have a mother who understands his struggles.
This is powerful. Please send this to every newspaper and magazine in the country and ask them to publish this. More people need to hear this. More people need to become enraged. The system is so broken. Also, please send this to your legislators. I am so very sorry for all you are going through.
Yes! This is criminal and needs to be publicized.
Criminal behavior like this has become legislated, protected by law, and is the rule not the exception. Families across this country are living with the repercussions of this cruelty and neglect. This speaks to the immorality of allowing private insurers to benefit from the insurance game. Their algorithms are constructed to benefit their profit, not to provide the best coverage of medical benefits. It’s so absurd at times I try to believe that this country cannot be such a Dickensian 19th century place, but in truth, it has devolved into it. Publicizing these crimes does not change the milieux in which they are conducted. The Congress of the US cannot even reign in the drug prices, poor insurance coverage on Medicare Part D drug plans, or prevent this behavior. Many of our representatives are accepting money from these entities. Like the opiate crisis fueled by drug manufacturers, these criminal acts were known for years and covered up by our own governing bodies while thousands of people died of overdoses from these illegally marketed drugs. Care in a residential facility is so much more expensive than prescribing pills and sending a patient in terrible pain: mental, emotional and physical pain, home to endure the adjustment to these drugs alone without observation and access to immediate health care providers skilled in the area of medicine needed. Insurance companies are profiting from this maltreatment and they have written the book, the law, on how to do it legally.
Wow! This letter is powerful, poignant, and a sad testament to what has become of our health care industry. I quit private practice and primary care in 2008 after only 8 years. I loved my patients, my staff, and my partner physicians. One of the main factors which lead me to quit was the never-ending insurance denials, peer-to-peer reviews on behalf of my patients, and the face to face conversations I had with patients where I had to explain that “we were denied once again”. I have since worked as a hospitalist caring for adults, and I try to provide the best care for my patients within the confines of my practice/hospital. Not surprisingly, it remains a difficult task with insurance denials, even in the inpatient setting. I pray for you, especially your son, and his recovery. Please continue your fight. We need more Mama Bears in this world like you.
I am so sorry to hear of your struggles. We are caring for a loved one
With serious behavioral health challenges. Our health care in as much as it egregiously separates mental from physical care, consistently denies care for those with no voice or agency to address it. Only others can give voice to the unjust treatment. Clearly your loved one needs and is entitled to better care .
I write my legislative representatives regularly and urge everyone else to do the same. In the meantime please know you are not alone in your love, devotion and outrage.
I am sad and enraged on your behalf. How dare corporate entities choose profit over your son’s life? And yet they did, they do, and they will.
His denial of treatment was beyond disgusting. I’m so angry that those are the only words I can say right now.
My prayers are with you and your son as you try to move forward in an unfair world.
Thank you!
results of a quick google search:
The nation’s largest payers have filed their fourth-quarter earnings reports, revealing which recorded the largest profits in 2022.
1. UnitedHealth Group: $20.6 billion
Total net earnings in 2022 were $20.6 billion, up 16.4 percent year over year. In the fourth quarter, net earnings attributable to shareholders were $4.76 billion. UnitedHealthcare’s total earnings from operations in 2022 were $14.4 billion, up 20 percent year over year.
2. Cigna: $6.7 billion
Total net income in 2022 was nearly $6.7 billion, up 24 percent year over year. In the fourth quarter, net earnings were $1.2 billion
3. Elevance Health: $6 billion
Total net income in 2022 was over $6 billion, down 1.3 percent from 2021. In the fourth quarter, net income was $949 million, down 16.5 percent from the same period last year.
4. CVS Health: $4.2 billion
Total net income in 2022 was $4.2 billion, down from $7.9 billion in 2021. Fourth quarter net income was $2.3 billion, up from $1.3 billion over the same period last year. The health benefits segment reported nearly $6 billion in adjusted operating income for 2022.
5. Humana: $2.8 billion
Total net earnings in 2022 were $2.8 billion, down 4.3 percent year over year. In the fourth quarter, the company posted a net loss of $15 million.
6. Centene: $1.2 billion
Total net earnings in 2022 were $1.2 billion, down 10.8 percent year over year. In the fourth quarter, the company posted a net loss of $213 million, down from a net income of $599 million year over year.
Technology is also making it easier for the industry to expedite denials of claims. Cigna now has an algorithm that enables doctors to process a claim in 1.2 seconds.
UnitedHealth made almost $5 billion, in the 4th quarter last year. Not $5 billion annually, which in itself is egregious given how they make their money (by refusing to pay for health care), but $5 billion profit in three months! This is money left over after the executives get paid their exorbitant salaries.
Capitalism is a great system for most products, but when the commodity is as vital as health care, which is arguably a human right, especially when living in the wealthiest civilization in the history of Civilization, capitalism is exposed to value greed over benevolence and amoral behavior is rewarded, not shamed. Humans have proven to be able to easily suppress empathy when it interrupts with their quest for wealth and the justifications for their indifference are easily found. To make matters worse, company behavior is driven by a requirement of expanding profits, and if UnitedHealth is only to make $2 billion over the next three months, panic will beset the C-suites. The path of least resistance is not against the competing interests armed with as many lawyers as the insurance industry but rather the helpless consumer who places a much higher value on their own health than the companies in which we contract with to ensure we receive adequate care when needed for our health. Their reason for their existence is predicated on that contract. But it is much easier to make high profits by not delivering on their end of the deal. Typically that behavior is termed “fraud” or “breach of contract”. why it is shrugged off as a normal operating procedure and not as a crime is beyond me. Their whole operational infrastructure is designed to slow down and/or prevent parting with the money that we give them at the beginning of each month. Given how blatant the denials are performed, and in such a remedial way by the use of unqualified employees who are unable to understand any nuance or how inappropriate their decision making is in the practice of Medicine, makes it feloneous in the opinion of many, if not most of us citizens. And aren’t laws just an agreed upon set of codes of conduct for the sole purpose of forming a civilized society? When this country was formed, it specifically declared that we are endowed “with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness”.
Yet insurance companies continue to operate with impunity, making money by conning a captured audience, by not honoring the contract we made with them, thereby often impeding peoples pursuit of these inalienable rights.
when is there enough profit to reevaluate where the denial line is drawn? There is obviously room to recalibrate how many denials need to happen to maintain profitability.
results of a quick google search:
The nation’s largest payers have filed their fourth-quarter earnings reports, revealing which recorded the largest profits in 2022.
1. UnitedHealth Group: $20.6 billion
Total net earnings in 2022 were $20.6 billion, up 16.4 percent year over year. In the fourth quarter, net earnings attributable to shareholders were $4.76 billion. UnitedHealthcare’s total earnings from operations in 2022 were $14.4 billion, up 20 percent year over year.
2. Cigna: $6.7 billion
Total net income in 2022 was nearly $6.7 billion, up 24 percent year over year. In the fourth quarter, net earnings were $1.2 billion
3. Elevance Health: $6 billion
Total net income in 2022 was over $6 billion, down 1.3 percent from 2021. In the fourth quarter, net income was $949 million, down 16.5 percent from the same period last year.
4. CVS Health: $4.2 billion
Total net income in 2022 was $4.2 billion, down from $7.9 billion in 2021. Fourth quarter net income was $2.3 billion, up from $1.3 billion over the same period last year. The health benefits segment reported nearly $6 billion in adjusted operating income for 2022.
5. Humana: $2.8 billion
Total net earnings in 2022 were $2.8 billion, down 4.3 percent year over year. In the fourth quarter, the company posted a net loss of $15 million.
6. Centene: $1.2 billion
Total net earnings in 2022 were $1.2 billion, down 10.8 percent year over year. In the fourth quarter, the company posted a net loss of $213 million, down from a net income of $599 million year over year.
A heart-wrenching narrative from a resilient mother!!
Science and the humanity of patient care often get buried in the system meant to enhance patient care.
I sincerely hope that your motherly efforts will bless you with great memories of your son as a person more than his illness.
Thank you for sharing your personal story.
Your “letter” is written so well that it made me furious at our health care system. As a pediatrician, I joke frequently that the denial by a high school dropout whose main job is to use their limited vocabulary by saying NO results in getting the insurance representative promoted. And the patient suffers while the denial helps pay the mortage on the CEO’s 5th vacation home. I feel for your son who sounds brilliant but very much in need of services; I would like to think that the care he was denied may have turned his life around. I hope he gets the help he so badly needs. And I hope that some day decisions like this one are made by educated people trained in health care, who put the patient first, and not just the bottom line.
Thank you, Dr. Wager.
Though I don’t know who initiated the denial–probably an algorithm–or, like you say someone with no medical background, the third, and final, appeal was handled by this MD psychiatrist I address, someone who had the opportunity to turn it around.
My son’s psychiatrist told me that during the appeal on video call, the insurance doc asked no questions, responded to nothing, and periodically looked at his watch. The letter sent to me was dated the day before that appeal–an accident? Or written before the appeal?
I’ll never know. It pains me more that the individual with the education and power chose not to help.
If you have not already, would you be willing to share this story or allow others to share more broadly?
Would you be open to speaking with a journalist? A lawyer? The fact that the denial letter was pre-dated seems extremely relevant.
I’m willing to share this story broadly. Please share this link with any/everyone you think could/would/should benefit from reading it.
I’m working on another article about this issue for a British magazine right now. It’s also part of the book I’m writing. I also read a version of this essay at a literary/arts event focused on social change and the journalist present featured our story.
I’m happy and willing to speak with anyone who wants to hear and/or broadcast this story. I can be reached at jpchan0495@sbcglobal.net OR @MielSloan
I’m not willing to take legal action beyond what I have, as a courtroom drama would be too intense and triggering for my son.
What I did do: at that time, two years ago, I tried to write directly to this doctor–original letter was returned unopened stating I had the wrong address; I confirmed with the company that it was the correct address. I called both companies involved but was given quite the run around: the company with which my son is insured said only the company that reviews claims can handle a dispute, but when I called that company they couldn’t help me because my son’s insurance ID # doesn’t come up in their system. When no one called me back, I filed a complaint with the state.
If I’d received a response from the company, I might never have written for a broader audience. I sincerely hope that people in the health insurance industry, or those in the medical field who might one day work for the industry, read this letter too. There are good people in all arenas, and I hope that something here would resonate with them before they make decisions about mental health care approvals and denials.
I’m honored to have been the journalist who wrote about Miel’s reading lo these many months. Still in draft form at the time, the essay Miel read that night, which she revised and posted here, was no less compelling.
In this country, we do not like to recognize mental illness.
We blame the patient, or the patient’s mother.
And so we don’t treat it.
We don’t want to acknowledge that it is a true illness:
an accident of Fate or Nature that could have happened to
any of us, or Any of Our Children.
That is just too frightening for most to
contemplate.
So as a society-in-denial
we refuse to spend the money to
treat such mysterious illnesses
that happen to “other people”
and “other people’s children.”
Thank you so much for writing this
beautiful, moving story.
Perhaps if enough people read it,
the story will awaken more minds
and hearts.
There needs to be accountability by insurance companies and their agents, including physicians, for the treatment of patients who require a more individualized plan of care. That is the right thing to do, and to those who say that such allowance is too expensive, I would suggest that any expense for a patient requiring a specialized therapy can be offset by those many other insured who pay their premiums and utilize less of their coverage than available to them. Our healthcare protocols should be guided by professional judgement; otherwise, they are a cruel sham.
Beyond imagining, how awful is this cruelty and indifference to all except the money that the company clearly worships as its only god. It is a commonplace that the only thing more broken than our nation’s healthcare is our nation’s mental health mishmash.
Like the others who commented, I hope your son can find better even in this morass; and more broadly that our nation will move from lip service for mental health, to meaningful, rational, sustained actions to improve it.
Your writing is powerful. Your son’s story, and yours, is devastating. It is scarcely believable that a denial letter would be signed without the name of any human being. I hope that Mx Anonymous psychiatrist reads your account. Mostly, I truly hope your son will find a way to improve.
You story made me so sad. I live in a country with free medical care but so under-resourced that it’s doubtful your son would get what he needs even here. I want so much for your son to have a happier ending than my daughter’s, and I wish you both love and luck.
Thank you! And I wish the same for you and your daughter.