Parents say Anthem decision hurts children with autism

Published: Oct. 2, 2019 at 6:15 PM EDT
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A Lexington provider for children with autism is facing an uphill battle with major health insurance provider Anthem, and it's the parents that are really paying the price.

Several families gathered to talk to WKYT at Autism and Behavioral Concepts off Nicholasville Road in Lexington. Autism and Behavioral Concepts is one of a small number of providers that use applied behavior analysts.

Recently, the director, Stephen Wood, received word that Anthem was going to cut reimbursements by 25 percent. "We contacted Anthem to negotiate those rates and we received a response from Anthem that they would be moving forward." Wood said. "There's an exponential increase in the number of kids who are being diagnosed with autism, currently one in 48, and there's a limited number of providers that can meet those needs.

The therapy, out of pocket, would be around $100,000 a year. Most parents can't afford to pay that much money, and places like Autism and Behavioral Concepts can't afford to keep Anthem on board.

Erin Phillips' son Matthew goes to therapy 40 hours a week. "Basically what would happen is our provider would not be able to accept Anthem anymore because at that rate, at that much of a cut, they could not fund their employees and that's really scary to me as a mom," Phillips said. "I think it's discriminatory. It's because they feel like they can."

Lashana Watson's son is 4-year-old Austin. He also goes to therapy 40 hours a week. She's worried about her little boy. "I don't know what we'll do. It breaks my heart because he can't live the best life he can live if he does not have ABA therapy. He will not be able to be a productive human being if he does not get the therapy he needs."

Here's Anthem's response to our story:

Anthem's goal is to help ensure access to high quality, affordable healthcare, including applied behavioral analysis therapy. One of the ways to help achieve that goal is to routinely analyze and rebalance professional fee schedules for medical services. This evaluation includes competitive benchmarking, analysis of government reimbursement, consideration of changes in care delivery models and the impact of any rate changes on the consumers we serve.

Anthem has adjusted the fee schedule for one service rendered by technicians under the supervision of a physician. However, Anthem has maintained its reimbursement levels for other services related to applied behavioral analysis therapy delivered by care providers.

We value the relationship we have with the care providers in our network and understand their concern about these changes. As the cost of healthcare continues to rise at an unsustainable pace, we have a responsibility as a healthcare leader to help address the challenge of affordability facing Anthem consumers. Anthem is committed to ensuring that the consumers we serve in need of applied behavioral analysis have access to such services.