Q & A with Lisa Kantor: How to Get Coverage for the Treatment of My Eating Disorder
August 21, 2013
Thank you to Lisa Kantor of Kantor & Kantor law for answering questions from the public on how to better obtain treatment for an eating disorder. For more resources and information, visit www.kantorlaw.net.
Question #1: Hi. I want to buy health insurance, but I don’t know what to get. My school’s insurance doesn’t cover pre-existing conditions, so my ED wouldn’t get covered. Any information is greatly appreciated. Thanks!
Answer: When are you looking to purchase health insurance? Beginning in 2014, the Affordable Care Act will prohibit insurance companies from excluding anyone with a pre-existing medical condition from coverage. See more here: https://www.healthcare.gov/. If you do not currently have insurance, there are many scholarships for eating disorder treatment…
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Question #2: What are the most important steps I can taking during an admissions or service continuation request at an eating disorder treatment facility to reduce the chance of a denial, or, should I be denied, to place myself in the best position to pursue legal action if it comes to that? I’d also like to understand what the treatment facility should be doing in this regard as well, because I’m not confident that they’re always as informed as they should be on this subject. Thank you.
Request a copy of your insurance policy before going into treatment. Without a copy of the policy, we can’t assist you in determining what your benefits are.
Our most important piece of advice? – YOU MUST STAY IN TREATMENT IN ORDER TO PURSUE LEGAL ACTION. Not everyone knows or remembers this piece – but it is incredibly important. Under ERISA, we cannot pursue legal action without being able to prove that you lost benefits. The only way you will have unpaid benefits is if you stay in treatment and pay out of pocket, or owe money to the treatment facility.
Our experience is that some treatment centers do a better job at this than others because they put more time and effort into the utilization review (“UR”) process. The UR process occurs when your insurance company “sends your case to review,” or when they are deciding how many more days to authorize, or when your treatment center asks for a doc-to-doc/peer-to-peer to discuss a denial, etc.. How can a facility be more proactive during admissions or after a denial? They should send in all of your medical and treatment records to the insurance company on time (and prior to any UR calls or telephonic appeals) and have your records in front of them during UR calls. They should document your treatment according to the American Psychiatric Association treatment guideline (APA guidelines) using our forms (follow this link) and they should take very detailed notes and confirm all conversations in writing. This means recording the name and number of the person with whom they spoke to at the insurance company, how long they were on the phone, were they transferred from one department to the next, etc. It is important to note if the insurance is having a qualified doctor conduct the review or appeal… or it is merely a claim representative. We have a strong relationship with many eating disorder treatment facilities, and we offer trainings on “Working with Insurance Companies to Obtain Coverage” to UR departments and staff, so that they can understand the most effective ways to communicate with insurance companies and document treatment.
Question #3: We spent a considerable amount of time researching in-network therapists for our daughter’s outpatient ED treatment team, only to conclude that few of the providers in the LA area had the necessary training and experience based on their published credentials. (In fact, based on the information we found, a high percentage of the in-network providers listed as having a specialty in ED had NO published credentials in the area that we could find.) As a result, we have built our daughter’s entire outpatient team using out-of-network providers based on referrals from her higher level care treatment team, ED referral sites, and a lot of research of provider Web sites.
The issue I describe above is a common problem in my experience, but many families don’t have the option of using out-of-network treatment because of the high cost and low insurer reimbursement rates for this care.
Answer: We always recommend that our clients follow the advice and recommendations of their treatment team….not their insurance company. Do not let the insurance company dictate your recovery! We understand the cost of treatment is incredibly costly, and some families must go to extreme measures to keep a loved one in treatment. We also understand how frightening and chaotic this time can be. This is where we come in: we work with your insurance company and treatment facility after a denial to seek reimbursement of the benefits available under your policy. If your insurance denies coverage for treatment, we can only help you recover these benefits if you (1) have an insurance denial in writing and (2) have STAYED in treatment.
Please note that we can help with any level of treatment denial –including PHP (Partial Hospitalization Program) and IOP (Intensive Outpatient Program).
Under ERISA (Employee Retirement Income Security Act), you have the right to file a lawsuit to recover unpaid benefits. If you do not have unpaid benefits, there is no ERISA claim. If you have been denied benefits by your insurance company for treatment, but leave treatment without paying anything out of pocket, you do not have unpaid benefits…and we cannot appeal the decision for you.
If you can document that there are no in-network providers qualified to treat your daughter, then you can argue that you should be reimbursed for the out of network provider at the in-network rate. Make sure you carefully document that (1) there are no in-network providers and (2) that your provider is qualified and (3) that you have followed all the appeal procedures.
Question #4: In your view, will the federal parity law, once the final rule is issued later this year (hopefully), provide families with meaningful legal recourse for addressing this all too common issue . . . or is a parity violation too hard to prove for this specific issue?
Answer: We believe that the final rules and regulations for Parity (MHPAEA) will force accountability onto insurance companies, and make it much more difficult for them to violate parity. However, be prepared for insurance companies to try to create other ways to circumvent the law and deny access to benefits.
Question #5: There are no treatment centers where I live, but it doesn’t matter because my insurance company won’t cover it anyway. I’m fairly certain that I need residential treatment. Is there any hope?
Answer: Have you received a written denial by your insurance company? Depending on the terms of your policy, you might be able to get a single case agreement for a treatment center away from home. Out of network facilities will sometimes enter into a single case agreement with insurance companies, which provides out-of-network treatment at a reduced in-network rate on a case by case agreement. The only way we can investigate this is if you:
• Get a copy of your policy from your insurance company or employer
• Send us a copy of your policy so that we can try to help
Question #6: How will the new Affordable Care Act and the FREED act affect Medicaid and Medicare in terms of getting residential or PHP care for eating disorders? Right now I have Medicaid which pays for virtually nothing. None of the ED therapist take it and it doesn’t offer and IOP or PHP coverage either. It has only been good for emergency care hospitalization and mental health hospitalization. All crisis based and not preventative or recovery oriented. I will be getting Medicare in the spring/summer 2014 and I know that is much better but it’s still very limited on where it pays for IP and no residential. I’ll also eventually get blue cross blue shield of Florida through my family living situation but the coverage on that isn’t great either. What can expect to change? What kind of access to care will be available beyond what I have now?
Answer: I’m sorry you’ve had such a difficult a time accessing treatment. I know how frustrating that can be. The simple answer to your question is that the FREED Act will help people with Medicaid. Eating disorders treatment will be made accessible to people of low income by including eating disorder treatment to the services covered by Medicaid. The more complex answer is that the FREED Act will amend already existing law, the Social Security Act, which was amended by The Health Care and Education Reconciliation Act of 2010 and the Patient Protection and Affordable Care Act (“ACA” or “Obamacare”). The ACA amended the Social Security Act, making it possible for the FREED Act to amend the Social Security Act so that the Federal medical assistance percentage (FMAP) shall be equal to the enhanced FMAP that is outlined in section 1905(b) of the Social Security Act (http://www.ssa.gov/OP_Home/
In essence, this translates to: medical assistance for eating disorder treatment services will be provided to an individual who has an eating disorder and is eligible for Medicaid. Also, the FREED Act allows for screening, counseling and pharmacotherapy as part of treatment in an inpatient setting, and “other necessary health care services” for people with Medicaid who have eating disorders. The specific language from the bill is found in Section 401, entitled, “MEDICAID COVERAGE FOR EATING DISORDER TREATMENT SERVICES.”
The Affordable Care Act will help people with eating disorders in several ways…here are just a few: Prior to the ACA, over 129 million people were denied insurance coverage because of a “pre-existing condition” such as an eating disorder. People with eating disorders also frequently discovered that their insurance benefits eliminated eating disorders via an “Exclusion” in their insurance policy. Beginning in 2014, the ACA prohibits denying coverage because of pre-existing conditions, including eating disorders. This will provide a huge relief to millions who have been denied access to health insurance because of an illness that was never their choice to suffer. Additionally, the ACA, by prohibiting an insurance company from denying benefits because of a pre-existing condition, all children under the age of 19, regardless of their health, must be provided insurance benefits. Until the ACA, families who had group health insurance could not get coverage for their children with pre-existing conditions. Also beginning in 2014, The Affordable Care Act will eliminate “lifetime maximums,” prohibiting insurance companies from placing a dollar limit on how much treatment they will cover over an insured’s (your) lifetime. The Eating Disorders Coalition, a Coalition of over 35 eating disorder organizations, is working very closely with individual advocates like yourself, and with Members of Congress, to ensure that eating disorders are addressed via the State Exchanges. Keep in mind that if the ACA is repealed, coverage for people with eating disorders will remain as it is, which is not good enough. One way that you can help ensure that eating disorder sufferers get proper treatment is to become an advocate with the Eating Disorders Coalition.
Dealing with and seeking treatment for an eating disorder can be both emotionally and financially devastating. Please do not hesitate to reach out to us with questions. We are available for a no-cost consultation, and we work on a contingency fee basis (meaning that we do not collect a fee from you unless we get your claim paid).