Families seeking treatment of an eating disorder may encounter significant barriers in obtaining insurance coverage. Very few families appeal the decisions of their insurance company, but most that do appeal succeed in obtaining additional coverage. Efforts to appeal denials of coverage may be more successful with the intervention and advocacy of an attorney coordinated with the efforts of the treating physician. Despite the complexity of appealing denials under either ERISA-governed plans, or plans controlled by state law, the early advocacy of an attorney may be dramatic. Because the timetable for litigation is often too slow to secure the insurance coverage for urgently-required treatment, you may find that letter-writing on behalf of your client is the most effective form of advocacy you can provide.
Understanding the Patientís Insurance Policy
- Read the insurance policy/summary plan description (SPD) to determine the medical and mental health coverage provided by the policy.
- Determine whether the plan is covered by ERISA since this will determine whether federal or state law controls disputes with the insurance provider. Most employer-based health insurance plans are covered by ERISA, while many individual, church or government-sponsored plans are not. Click HERE for more information.
- Identify the written and oral appeals procedures specified by the plan.
Identify the Specific Reason for the Denial
- Denial because treatment is not "medical"
- Denial because patient does not meet specific medical criteria
- Denial because the requested facility or specialist is out of network
- Denial of comprehensive care that is "not covered"
- Denial of day treatment or residential care
- Denial because patient has met coverage limits or because medical or mental health benefits have been exhausted
- Denial of continuing care
Understanding the Posture of the Specific Denial
- Did the client attempt to initiate a pre-authorization process?
- Has the client received an oral or written denial of coverage? Date?
- Has the client filed a formal written or oral appeal? Date? Documentation?
- Has the clientís appeal been formally denied?
- Has the client filed a secondary appeal? Status? Documentation?
- Has your client exhausted their appeals process?