Many insurance companies have policies or practices that create challenges and confusion for patients who are seeking insurance coverage for the treatment of an eating disorder.† Despite your frustration and outrage with a denial or termination of treatment, there are steps you can take to educate insurance companies.† This information is designed to help you secure treatment for your family member who is suffering from an eating disorder. Donít give up!† Use denials as an opportunity to educate insurance companies about the necessity of treatment and the devastating consequences of denying coverage.
General Strategies for Communicating with your Insurance Company, Obtaining Appropriate Levels of Care, and Appealing Denials from Insurance Providers.
Know Your Insurance Policy
- Get a written copy of your insurance policy, including the summary plan description. You can do this by calling the phone number on the back of your insurance card. The plan should inform of which benefits are covered and which are not. Unfortunately, it is very common for insurance representatives to misrepresent covered benefits (usually unintentionally) so it is essential to get the plan in writing.
- Figure out which treatments are funded through health benefits and which are funded through mental health benefits.
- Figure out the appeal procedures for your plan, including any expedited appeal procedures.
Work with the Patientís Doctor to Understand the Treatment Plan
- Inform the patientís doctor of the limitations and benefits of the insurance plan. Her approach to recommending services may vary depending on the scope of coverage of your insurance policy.
- Get a written copy of the doctorís prescription for care.
- Ask the doctor if he or she would be willing to send a letter or make a telephone call if the insurer denies care.
- Send or fax a copy of any written insurance denials you receive to the patientís doctor.
- Request a written copy of the practice guidelines the insurer is using. Send or fax a copy of the denial and the written practice guidelines to the patientís prescribing physician.
General Tips for Communicating with your Insurance Company
- Do not be pressured into accepting the first option offered by the health plan [Link].
- Document all conversations.
- Communicate directly with the Medical Director or someone else empowered to make decisions.
- Use communications with insurers as opportunities to educate them about eating disorders and appropriate treatment.
- Request a written copy of the practice and/or clinical guidelines the insurer is using. In most cases they are required to provide these. [Link ]. Send or fax a copy of the denial and the written practice guidelines to the patientís prescribing physician.
- In your communications with insurers, submit published practice guidelines (catalogued here (link to Basic Characteristics)) to justify the treatment the physician is seeking.
- Try to work proactively with the insurer to reach a satisfactory resolution, even if the plan does not provide the coverage for required services. If the service being requested is clearly excluded, appealing the denial is unlikely to be successful. Nevertheless, a letter to the medical director documenting the need for treatment and risks of not receiving it may, sometimes, cause the insurer to issue a waiver, flex their benefits, or re-examine their policy.
- If the insurer does not provide a benefit for a recommended level of care (some policies have inpatient and outpatient, but no residential or partial hospital benefit), ask if the insurer will flex the benefit.
Responding to a Denial of Coverage (More Denial-Specific Strategies Follow)Appealing denials of treatment is critical. Very few families appeal the decision of their insurance coverage, but most of those who do appeal, succeed in obtaining additional coverage.
- Clarify the reason for the denial. A successful appeal depends on a clear understanding of the reasons for the original denial and carefully addressing these reasons in the appeal. Ask to speak to the Medical Director and request a detailed written explanation of the denial. See the next section for denial-specific strategies.
- File a written appeal (see sample letters) following your planís appeal procedures. In many cases you may be able to request an expedited appeal. See below for denial-specific appeal strategies.
When All Else Fails . . .
- If the insurer does not respond, you can appeal the insurerís decision through your state's Insurance Commissioner.
- Speak to your employer, union, or human resources department since they sometimes have additional leverage that can encourage insurers to provide the needed service.