Many insurance policies create challenges and confusion for patients who are seeking insurance coverage for the treatment of an eating disorder. When a patient or family is notified of a denial or termination of treatment, be proactive in assisting the family in appealing the decision. Use denials as an opportunity to educate your insurance company about the necessity of appropriate treatment and the devastating consequences when treatment is unavailable. With guidance and support, many families are successful in obtaining needed services via appeal, waiver, or negotiation, even in the case of plans with limited coverage. Often, your help and persistence will result in a favorable outcome.
General Strategies for Communicating with Insurance Providers, Obtaining Appropriate Levels of Care, and Appealing Denials.
Know The Insurance Policy
- Ask patients or families to obtain a written copy of their insurance policy, including the "summary plan description." They can do this by calling the phone number on the back of thier insurance card. The plan should be explicit about 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.
- Help patients and families to figure out which treatments are funded through "medical" benefits and which are funded through "mental health" benefits. Consider this a strarting point since many plans are willing to "flex" benefits.
- Help patients and families to figure out the appeal procedures for their plan, including any "expedited appeal" procedures.
Be Flexible in Recommending a Treatment Plan
- Work, with patients and families to individualize the treatment plan to match their benefits.
- Understand the limitations and benefits of the insurance plan. Recommend services, if possible, that are covered.
- Be clear with families about the options for care. Residential treatment may be optimal, but unavailable. Short term psychiatric (or medical) hospitalization, though not ideal, may be a reasonable alternative and a covered benefit.
- Be willing to send a letter or make a telephone call if the insurer denies care.
- Request a written copy of the practice guidelines the insurer is using. Use the information contained in the denial and the written practice guidelines to be an advocate for appropriate services using an evidence-based approach.
General Tips for Communicating with Insurance Providers
- Use communications with insurers as opportunities to educate them about eating disorders and appropriate treatment.
- Communicate directly with the Medical Director or someone else empowered to make decisions.
- Do not be pressured into accepting the first option offered by the health plan. [Link].
- Document all conversations.
- 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 to justify the treatment you are recommending.
- Involve other members of the treatment team in communicating with the Medical Director. Make certain that the recommendations of the treatment team are consistent, justified, and supported by up-to-date information.
- 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.
- 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.