When someone needs treatment for a mental health or substance use disorder, the last thing they or their family should have to worry about is an insurance coverage denial. Often, however, insurance denials are a major hurdle to receiving the right care, at the right time, and at the right level. The 2008 Mental Health Parity and Addiction Equity Act (Federal Parity Law) and other applicable state and federal laws provide consumers with important rights relating to insurance coverage, including requiring that illnesses of the brain are treated the same way as illnesses of the body.
Often patients are left high and dry after an insurer denies their requested treatment through a process often referred to as utilization review. These reviews are used to assess the “medical necessity” of the treatment, but unfortunately, insurers often make flawed decisions by using improper guidelines as highlighted in the Wit vs. United court decision. In addition, adverse determinations are sometimes based on the insurer or third-party administrator’s conclusion that the treatment is not a covered benefit under the policy.
Once a denial of insurance coverage is made, patients and their families are often at a loss as to what to do next. Although there is an appeals process that requires the insurer to reconsider the adverse determination, the process is very complicated and can easily overwhelm patients and their families. There are dozens of different appeal pathways that might apply given all of the details associated with the patient, the type of insurance, the reason for the denial, and so on.
For that reason, The Kennedy Forum and The National Alliance on Mental Illness (NAMI) recently released a report titled: “The Health Insurance Appeals Guide: A Consumer Guide for Filing Mental Health and Substance Use Disorder (MH/SUD) Appeals” to help consumers navigate the insurance appeals process. The Guide not only provides tips related to filing a successful mental health and substance use disorder appeal, but it also can be used to appeal denials related to medical/surgical care.
The 75-page Guide is made up of several sections with the aim of educating a wide range of stakeholders about the fundamentals associated with health insurance, how to file several different types of appeals, and what to do if the appeals are not successful in overturning the original denial. The Guide was written by several industry experts who work with consumers on both the internal and external appeals process.
For additional information, The Kennedy Forum previously published an issue brief entitled Filing an Appeal Based on A Parity Violation, which discusses many of the challenges associated with the current health insurance appeals system. The issue brief makes several recommendations including the need to standardize the appeals process across market segments and state lines.
Another helpful resource is the resource page on www.parityregistry.org, which lists information via a state map, key regulator contacts, and identifies other important resources when filing a complaint or an appeal.