How to Fight Insurance Discrimination
“…Denial of benefits is, in fact, denial of care.”
Dr. Arnold Andersen, Director of Eating Disorders Services
University of Iowa Health Care
Hundreds of families have used ANAD for help in coping with harsh and sometimes unethical impediments to treatment. We continue to actively fight discrimination in a number of ways.
Many insurance policies exclude psychiatric conditions; many specifically exclude reimbursement for eating disorders. THIS IS WHY WE CAMPAIGN FOR MENTAL HEALTH PARITY LAWS. We want mental health, including eating disorders, to be covered the same as medical illnesses. Many are shocked to discover that insurance covers only a small portion of expenses for eating disorders treatment.
Often there are low caps, particularly on inpatient days. Many will only cover expenses that are “medically necessary” but will not rule on medical necessity until well after treatment has been initiated. Often upon review it is decided that care for an eating disorders is not deemed medically necessary.
Steps to follow in coping with difficulties in insurance coverage for treatment of eating disorders:
1. Read your insurance policy and know what is covered and what is not. If you have difficulty understanding the policy, have someone outside the insurance provider read the policy, e.g., often a treatment center, physician’s office, or an attorney can help you interpret benefits. Do not allow only the employees of the insurance company to interpret benefits.
2. Know the law in your state. Some states have mental health parity that includes eating disorders; others do not. For instance, in California, coverage is mandated by AB 88, the mental health parity law, which specifically includes anorexia nervosa and bulimia nervosa. If you are in an HMO in California, contact the State of California HMO Help Center for further assistance at 1-888-466-2219. Mental health parity is a reality in California. Let’s make it so everywhere!
3. Keep excellent records. Keep track of all communication, including dates, times, names of persons contacted, phone, fax, and e-mail messages with copies of all written correspondence. It may be helpful to keep everything in a folder, together with any receipts and other related papers.
4. Get letters of support from all professionals treating the patient stating why the treatment is medically necessary and, if applicable, why the particular choice of facility is appropriate. These letters should come from the patient’s doctor, therapist, dietician or any other health professional.
5. If treatment is denied, appeal the decision by phone and write a letter immediately to the insurance company. Address it to the medical director. Indicate in your appeal that if your needs are not satisfied, you are not afraid to contact the state insurance commission, the media, or an attorney.
6. Find out the reason for denial and get it in writing. If the problem is an out-of-network facility, find out if there is an in-network facility that specializes in eating disorders. If there is not one, it may be an adequate basis for demanding coverage of an out-of-network facility.
7. Try to get the medical repercussions of the illness covered by medical insurance and not mental health coverage.
8. Consider asking your doctor and the treatment facility to continue to treat while they appeal to the medical director of the insurance company, but be aware that you may have to pay the bill if the decision is not in your favor.
9. Make sure that everyone is aware of the American Psychiatric Association’s Guidelines for the Treatment of Patients with Eating Disorders.
10. Negotiate with the treatment center regarding cost.
11. If necessary, begin to look at alternative care and resources. Community mental health agencies have a sliding fee. Medical schools and university centers sometimes provide low-fee clinics run by psychiatric residents in training and are supervised by faculty. Many hospitals accept Medicare and Medicaid but have no staff members with experience. If the treatment center is funded in part by county, state, or federal funds, they may be required to make appropriate care available. Apply for these benefits if you qualify.
12. Check the web for free clinical trials.
13. Check for research programs: National Institute of Mental Health, The Academy of Eating Disorders, Clinic at New York State Psychiatric Hospital (212-543-5739), and The American Academy of Child and Adolescent Psychiatry.
14. If your insurance company is through an employer, send a letter to that employer letting them know of the inadequate coverage they offer.
15. If appeals are not successful, or the process is lagging, do not hesitate to call the state Insurance Commissioner, any state consumers’ rights commission or your state and federal legislators to ask for their support.
16. Consider contacting an attorney. Sometimes just the suggestion of using legal resources will get the attention of an insurance company. Sometimes a letter from a lawyer is all that is needed. Sometimes legal action is necessary.
American Journal of Psychiatry Deems ALL Eating Disorders Dangerous
A 2009 Longitudinal study by Crow et al determines that there is an increased rate of mortality for bulimia nervosa and eating disorder not otherwise specified. The eating disorder not otherwise specified diagnosis is frequently looked at by insurance companies as a “less severe” eating disorder, often leading them to deny inpatient treatment coverage. This new study shows that this diagnosis has an elevated mortality rate similar to that of anorexia nervosa. The study also found that there is an increased rate of suicide for all eating disorders. To read more about this study, click here.
Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)
The law is effective July 1, 2010 for plans that BEGIN on or after July 1, 2010. The calendar year plans –what most people have thru their employers) are to BEGIN following the rules in January, 2011…
The law does not require private plans to offer coverage for mental health or substance use disorders. It does stipulate that if mental health conditions are covered, coverage must be equitable with coverage for other health conditions. That means insurers cannot have stricter limits or higher co-payments for mental health services than they do for other types of care (except to the extent that a state parity law requires broader coverage). Specifically, it prohibits group health plans that offer coverage for mental health and substance-use conditions from imposing treatment limitations and financial requirements on those benefits that are stricter than for medical and surgical benefits. With regard to out-of-network coverage: If a plan offers out-of-network benefits for medical/surgical care, it must also offer out-of-network coverage for mental health and addiction treatment and provide services at parity. With regard to State Laws: MHPAEA preserves strong state parity and consumer laws.
To find out your state’s parity laws, please visit: http://takeaction.mentalhealthamerica.net/site/DocServer/Parity_Chart_2008_1_.pdf?docID=1161