Lawsuit alleges Texas Children’s Health Plan’s conspiracy, fraud, negligence, and retaliation: placing children in harm’s way

HOUSTON, Dec. 17, 2020 /PRNewswire/ -- On Site Counseling, Inc., a Houston-based behavioral and mental health counseling firm, filed a countersuit against TCHP in the Harris County District Court (Cause No. 2019-87352 and hereinafter referred to as the "Lawsuit"). The Lawsuit alleges "civil conspiracy," "common law fraud," "breach of contract," "negligent misrepresentation," and "retaliation," amongst other allegations. For the benefit of the general public, On Site Counseling demands an investigation, by the Office of Inspector General, into the largest children's health insurance plan in Texas. The Lawsuit further alleges a practice of systematic denial of claims and access to care for hundreds of school-aged children with behavior problems. 

Lawsuit alleges civil conspiracy and discrimination by TCHP

TCHP is, by far, the most extensive health plan receiving monthly capitated funds to provide insurance coverage to more than 385,000 children and adolescents in the Houston area. Troy Marsaw, President, and CEO of On Site Counseling, alleged in his Lawsuit that TCHP intentionally and systematically denies On Site Counseling's authorizations to treat its Members and further alleges discrimination because the vast majority of its Members are African American or Latino. 

In 2015, the State of Texas provided Texas Children's Health Plan with $944 million in Medical and CHIP funding. TCHP receives funding from the state based upon a capitated payment system. Capitation payments are fixed, pre-arranged monthly payments received by the Health Plan per patient enrolled, or per capita; thus, these funds are provided to TCHP regardless of the services that they provide. At the time of this release, the figures for subsequent years had not been made readily available. 

The Lawsuit alleges a systematic denial of all authorizations sent by On Site Counseling to TCHP. In the affidavit of Dr. Ruffin, she states that "…TCHP's in house professionals … (were) … unusually stringent when reviewing On Site Counseling's request for treatment authorizations…" She further states that "...On Site Counseling appeared to be singled out and subjected to requirements that others were not…" (see attached "Exhibit 1 – Affidavit of Dr. Ruffin). 

"They (TCHP) get paid either way, so if they don't use the money, then it is more profitable for the health plan," says Marsaw. "Texas taxpayers need to demand an investigation." Marsaw is determined to continue to advocate for those Members who continue to be denied services by TCHP. On Site Counseling has provided care to more than 50,000 patients over the 19 years and operated in 8 states. 

Record # of complaints against TCHP

A review of records in the Texas Department of Health and Human Services shows TCHP has been fined 1.9 million dollars since 2015, with 291 complaints about denial of claims and failure to provide access to behavioral services providers. The largest number of complaints involve a denial of access to care in the behavioral/ mental healthcare arena.

TCHP's routine denials for "no clinical documentation" are examples of how they deny their Members access to mental/behavioral healthcare even if their Members are in a crisis, emergent or urgent situation. The Lawsuit alleges the "misuse and abuse" of these routine "no clinical documentation" denials for authorization to treat when a child/Member most often has never been to a mental health professional in his/her lifetime. TCHP knowingly makes these request, specifically to out of network providers, with the knowledge that there is no possible way a provider could supply "clinical documentation" of a member that has never been seen.   

Retaliation by TCHP

According to the Lawsuit, TCHP's retaliation towards On Site Counseling began when the counseling firm was terminated "without cause" from the network of Texas Children's Health Plan (TCHP) in October 2017 solely for "complaining" about TCHP's unreasonable amount of time to credential providers into their network. In the Lawsuit, On Site Counseling has claimed retaliation as being the cause of termination.   

Marsaw calls the Lawsuit the "worst form of retaliation." Marsaw says, "I'm fighting for the children of Texas. Texas Children's Health Plan wants to use their immense profits under the guise of helping children, to silence me from warning Texas parents. It will not stand." 

Video release immediately proceeds lawsuit

For the past two (2) years, TCHP has continued to oppose On Site Counseling's attempts to provide much-needed services to the health plan members. Recently, On Site Counseling's continuous battle with TCHP was detailed in a video that received media attention. The video, "Blowing the Whistle to protect Houston Kids" which can be viewed here, was part of an investigation by Dolcefino Consulting and can be found at www.dolcefino.com or on Dolcefino Consulting's Facebook page.

Just days after the video release, TCHP filed a lawsuit in Harris County alleging a "smear campaign." The lawsuit not only lists the Texas Children's Health Plan but also Texas Children's Hospital. If Texas Children's Health Plan is independent of Texas Children's Hospital, why is the hospital listed as a Plaintiff on a lawsuit brought about by the health plan? 

Lawsuit alleges TCHP's breach of contract and negligent misrepresentation.

TCHP's Provider Directory lists a total of 362 behavioral healthcare/mental health care providers in the Houston area. This number is minimal compared to the 385,000 Members who belong to their network. Of the 362 providers, only 20 could take a new patient for an evaluation within thirty (30) days. It is evident that with only 362 providers in the network, the over 300 thousand Members cannot receive the access to care nor the continuity of care that is contractually required of TCHP to its Members. TCHP contracts with the State of Texas to provide mental health care to its Members. If there are not enough providers, its Members are unjustifiably denied access to healthcare. 

The public should be concerned, especially considering recent deadly school shootings, a spike in teen suicide rates in Texas and throughout the country, and the increased domestic violence during this global pandemic. 

On Site Counseling is committed to preventing such occurrences by taking the proactive approach instead of being reactive. To date, TCHP still denies authorizations to On Site Counseling to treatment for mental health services for its Members. It is disparaging for TCHP to deny their Members before ever being seen, especially when an emergent evaluation may lead to immediate treatment that could save lives!

About On Site Counseling, Inc.

On Site Counseling, Inc. provides optimum, systemized, behavioral and mental health care, support, and counseling services under one roof in Houston, Texas, and surrounding counties. On Site Counseling welcomes patients, on a voluntary and involuntary basis, with the support of an innovative, professional team of medical doctors, psychiatrists, nurse practitioners, clinical psychologists, along with licensed clinical social workers and counselors. On Site Counseling is one of the companies retained by Houston Independent School District to provide services to children in need of behavioral health care.

For more information, please contact On Site Counseling, directly at 713-942-8100.

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SOURCE On Site Counseling, Inc.