March 7, 2019

 

 

 

Mrs. Melania Trump

The White House
1600 Pennsylvania Avenue NW
Washington, DC 20500

 

Dear Mrs. Trump:

 

            This letter is being sent in response to the town hall-style discussion you hosted in Las Vegas as part of your “Be Best” tour regarding the opioid epidemic our country is presently facing.  The State of Kansas is suffering as much as any part of our dear County with the tragic disease of addiction.  But, in the Kansas, there is an obstacle to treating the disease of addiction that not every state has.  Finding a resolution to this obstacle is the reason I am writing this letter to you.  In Kansas, the large insurance carrier Blue Cross/Blue Shield (BCBS) has engaged in fraudulent activity when disseminating insurance benefits to cover the mentnal health/substance abuse treatment many Kansans need. 

 

For almost a year, I have been reaching out to those in a position of authority who have the ability to initiate an investigation into this serious case of insurance fraud.  Up to now, my efforts have been unsuccessful.  The Governor, Insurance Commissioner, our Senators and Representatives have all refused to investigate this extensive white‑collar crime. I know your family has been touched by the disease of addiction.  The untimely death of your husband’s older brother, Fred, is a terrible tragedy.  I only mention this private heartbreak because President Trump has spoken of it publicly. 

 

My work experience gave me first‑hand knowledge that these allegations of insurance fraud are true.  The reason for this crime has been to increase profits for BCBS shareholders.  Some of the ways BCBS is withholding benefits from policy holders the insurance benefits they deserve includes the following:

 

1. The authorization of substance abuse (SA) benefits was being based upon the use of clinical criteria designated for a higher level of care (LOC) than the actual LOC being requested

2. A “fail‑first” policy was being used to authorize benefits, despite the use of such a policy being mandated as illegal per federal law MHPAEA.

3. The outcome of any physician review became moot once NDBH‑KS made the patient-assigned Care Manager responsible for the final determination of patient benefits.This, despite the fact that Care Managers never have the professional authority to override the benefit determination of a physician.

4. The decision was made by New Directions Behavioral Health of Kansas (NDBH‑KS), a third‑party payer hired by BCBS, to stop doing physician reviews for patient cases deemed to be at the “lower level of care.”These lower levels of care included the Partial Hospitalization, Intensive Outpatient, and weekly group session levels of care.

5. Regardless of the clinical justification to overturn a denial of benefits, treatment benefits continued to be consistently denied once the denial had been issued by NDBH‑KS.

6. Letters of appeal were routinely, if not always, reviewed, and benefit determinations made, by NDBH‑KS employees who were not professionally qualified to complete this type of work, including those employed as “Care Managers” and even A “Care Manager” is professionally licensed as a Therapist or a Nurse.Employment as a does not even require a GED level of education.

7. NDBH‑KS refused to speak with BCBS‑KS Customers to explain reasons a treatment episode that quite obviously met criteria for benefit authorization was being denied.These BCBS‑KS Customers, patients of Valley Hope Association (VHA) were being denied education on ways to advocate for him/herself per direction of the leadership at NDBH‑KS and VHA.

 

              In summary, I am asking for your help to initiate an investigation into the white‑collar criminal activity BCBS‑KS has engaged in through their third-party payor, NDBH‑KS.  The type of patient most affected by the purported mismanagement of BCBS‑KS healthcare benefits includes middle‑class American citizens who are employed and pay a monthly insurance premium that often includes coverage for a spouse and eligible children.  This is the type of American citizen that is the glue holding our country together.  Their children are our country’s future. These people are not asking for a handout, they are asking for the chance they have earned to live as a clean and sober person.

 

Sincerely,

 

Kristy L. LeClair, MSEd, LMHP, CPC, LPC

Phone:  (___) ___-____

e-mail: inscommr@outlook.com