By guest blogger Joe Feldman, President, Feldman Associates (Wilmette, IL) and board member, The Kennedy Forum Illinois
Parenting comes with a menu of general worries: keeping our children safe, raising them to be responsible adults, and safeguarding their health. Very seldom does that list of worries include sending your teen to an inpatient addiction treatment program, a residential facility for mental health care, or a wilderness program.
Even further from our minds is the thought that insurance coverage for such critical care is often denied, despite years of paying into the same health plan and being protected under laws, such as the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). In the same way that lifesaving treatments for physical ailments often cost more than the average annual salary in America, lifesaving treatments for mental health and addiction are equally expensive. One assumes that their health insurance will cover diseases of the brain like any other organ in the human body. Unfortunately, this is most often not the case.
When families are advised by doctors to seek hospital, residential, or other inpatient levels of care for their child’s mental health or substance use disorder, they are typically focused on saving that child’s life—not the insurance obstacles they will most likely face.
These insurance denials come in a wide range of flavors, including the assessment that a patient’s condition does not meet an insurer’s standard for “medical necessity,” a failure to meet preauthorization requirements, and more. When trying to save your child’s life, the insurance process only fuels toxic stress levels. I know this from years of work to overcome insurance denials, an experience I’d wish on no other parent.
That is why I compiled the ten steps below—to help families navigate the insurance process and have a better shot at securing the mental health and addiction treatment coverage they need, deserve, and pay for.
Step 1: Request a copy of your complete insurance policy.
The “complete” policy is beyond the documentation you typically receive when you purchase your insurance plan. Across hundreds of pages, it should include detailed information required by law, such as Non-Quantitative Treatment Limitations (NQTLs), which may be important for more complex mental health and addiction claims. It’s also something that you’re entitled by law to receive upon request, so don’t let the insurance company (or your employer) waffle around regarding your legal right to see the full policy. Please note, these documents are sometimes called Summary Plan Descriptions (SPDs), Certificates of Coverage (COC), or Evidence of Coverage (EOC).
Step 2: Ask your doctor, psychiatrist, counselor or other provider for a “medical necessity” letter.
If you or a family member are diagnosed with cancer or have a heart attack, insurers are unlikely to ask whether the treatment in a hospital or doctor’s office is “medically necessary.” For mental health and addiction treatment, what is “medical necessary” may be one of the first questions an insurer considers.
There is, of course, no one better able to make that assessment than the treating doctor, counselor, or other care provider. So, request from the treating provider a written letter detailing their professional judgment and determination that the care is medically necessary. This letter can be crucial if your insurer ever questions whether the care you or a loved one receives is necessary and appropriate. If there are multiple treating providers, try to get as many as possible to document the basis of their specific diagnoses and treatment recommendations.
Step 3: Consider asking a family member or friend for help dealing with insurance claims.
When you are suffering from a mental health and/or substance use disorder (or perhaps helping your spouse or child), focusing on the needed care may consume all available attention and energy. Therefore, it may be helpful to ask a family member, friend, or medical claims denials professional for help in dealing with insurance claims. Sharing these “10 steps” may help them to understand the assistance you need.
As described in the Journal of Medical Ethics, “Patients representing themselves benefit from enhanced autonomy and informed consent. But patients are in varying states of vulnerability and may be unable to represent themselves adequately. Therefore, external support may be beneficent, if not necessary.” Parents and individuals seeking mental health and/or addiction treatment services are certainly candidates for such vulnerability, whether in accessing care or in dealing with questions about their insurance coverage.
Insurers will provide, upon request, a form you can fill out to authorize someone to help you. This will allow the designated person to receive personal health information and other confidential health communications.
Step 4: If the treating provider deals directly with your insurer, be sure they let you know of ANY issues they encounter.
Some mental health or substance use disorder providers will file an insurance claim for you or your family member. However, because demand for mental health treatment exceeds supply, many providers will leave that messy and complicated business up to the insured. If providers do file claims on your or your loved one’s behalf, be sure they keep you informed of the claims they file and any denials, adjustments, limitations, or other surprises about the insurance coverage. Knowing about potential issues in advance will help to expedite the process. It is best to try to resolve an issue before a claim unexpectedly goes unpaid and the medical bill comes your way.
No matter who files a claim, be sure to keep copies of all the claims, noting the dates of submissions, along with any explanation of benefits (EOBs).
Step 5: Take detailed notes of all your contacts with your health insurer.
Through the course of your treatment and claims submissions, it’s common to have phone calls or other contacts with your health insurer. You may initiate those to check on the status of a claim, or you may receive a call from a customer service representative. In any event, it’s crucial to carefully document any and all contact you have. At a minimum, write down who you talked with and when, their company ID number (they will give you their ID number upon request), what you discussed, anything they said they would do or that you are supposed to do. In short, write down everything you discuss. Try to document all contact in a consistent format and store it in a manner so that you (or your advocate) can access that information when needed.
Step 6: Leave clinical questions to the clinicians.
As noted above, insurance company customer service representatives are often important contacts when it comes to checking the status of claims or clarifying specific information contained in a claim. However, if they ask how your treatment is going or inquire about your child’s progress, etc., do not answer.
It is inappropriate for anyone from your insurance company to ask such questions. Providing this type of information could directly impact their assessment of your care and whether they will pay the claim. You can consider responding with something along the lines of, “Thanks for your interest, but I’ll leave that to the doctors.”
Step 7: Watch out for red flags in claims denials.
It’s helpful to be aware of many of the reasons insurers commonly deny coverage for mental health and substance use disorders so that you know what to watch out for. These reasons include:
- Treatment wasn’t pre-authorized.
- Treatment wasn’t included in your policy.
- The maximum number of appointments has been reached.
- Treatment is not resulting in sufficient progress.
- Treatment is resulting in progress, so it is no longer needed.
- Treatment is not medically necessary.
- The treating provider is out-of-network.
- Treatment will be partially reimbursed at a lower rate.
These reasons for denial may or may not be valid or legal. Incorrect denials may require follow up with the insurer, perhaps filing an appeal or considering litigation. In short, do not assume that an initial denial is the last word on whether your insurance claim should be paid.
Step 8: Know your rights under federal and state laws.
Because mental health care and insurance coverage has long been a point of contention between insurers and their customers, many laws have been enacted to provide consumer protection and ensure that claims are treated properly. The Kennedy Forum’s Don’t Deny Me website, www.dontdenyme.org, provides helpful information around this topic.
The MHPAEA is among the most important federal laws when it comes to insurance coverage for mental health and substance use disorders. And many states are now enacting their own parity laws to bolster the MHPAEA.
It also is important to understand your rights to file an appeal, including certain due process rights afforded to you for both internal and external appeals. Additionally, you have a right to file a grievance with your health insurance and/or the applicable regulator.
But just because there is a law or regulation on the books, that doesn’t mean insurance companies are following it. It is up to you to fight for the protection you purchased.
Step 9: Consider insurance advocates or even litigators for support.
Fortunately, the challenge of complex insurance claims has resulted in the creation of specialized service providers who might be helpful when it comes to filing claims, completing administrative appeals, or even potentially initiating a lawsuit.
It is best to start this process by contacting the applicable regulator who oversees your type of health insurance. All of the key regulators are listed on the resource page at www.parityregistry.org. Typically, regulators can provide limited, initial assistance in helping you sort through your rights and health insurance company obligations. They may also be able to refer you to additional resources like an ombudsman or state attorney general contact.
In addition, professional insurance advocates are available to work with you to review your insurance policy; assess the available policy benefits; request pre-authorizations (if required and appropriate); coordinate with your provider to ensure that the right details are included in their bills; file claims and follow-up; and develop and file administrative appeals.
A growing number of attorneys across the country are investing time in this relatively new area of litigation. While litigation is a significant step and not necessarily appropriate for all situations, it may be helpful to keep such a possibility in mind as you take some of the steps described above. Actions such as documenting communications with your insurer, having a letter from your doctor describing the “medical necessity” of the treatment, and getting timely feedback from your provider if they encounter issues with a pending claim may be important if and when litigation becomes a consideration.
For both professional insurance advocates and attorneys—make sure you address fees up front before any work is done. If you need a recommendation for a consumer advocate or attorney, email The Kennedy Forum at firstname.lastname@example.org.
Step 10: Remember, you are not alone.
Getting the insurance coverage you have paid for shouldn’t be hard, but sadly, it sometimes is. Being prepared and proactive can make a huge difference in minimizing frustrations and challenges.
These ten steps reflect the wisdom and personal experiences of several experts in mental health insurance, as well as lawyers who are active in litigation of mental health claims. While we would all hope that insurers will naturally do the right thing, empowering individuals to advocate for themselves and their loved ones may be the most impactful thing of all. Recovery from mental health and substance use disorders is possible with treatment and insurers must play their role. Everyone deserves a chance to live a healthy life—body and mind.