This great article comes to us from our friends at Kantor & Kantor. Such great advice! – Rachel
1. They utilize internal guidelines. Many insurances companies will make decisions based upon their own internal guidelines. They will deny or approve claims for eating disorder treatment, or deny a specific level of treatment, without providing transparency for how these decisions are being made. For a clear and simple description of what insurers should be using (American Psychiatric Association guidelines) to determine appropriate levels of eating disorder treatment, click here. Become familiar with the APA guidelines and challenge insurers to follow them.
2. They use internally biased medical reviewers. Insurance denials often come through strangers who are referred to as “independent medical reviewers.” These reviewers make critical life and death decisions about a person’s health and recovery, often dolling out treatment one day at a time. It seems that they focus more on an insurance company’s “criteria” than on the clinical rationale of the patient’s treatment team. Furthermore, most of the time these medical reviewers are not specialized experts in eating disorders, and have limited knowledge about the illness.
3. They have a bottom line, and it’s not your health. Sometimes having health insurance is not actually about your health. Some insurance companies are all about making money, even if it’s at the expense of your wellbeing. When insurance companies are calling the shots (rather than medical experts) for oftentimes very serious medical conditions, it most certainly draws attention to the offensive bias that can affect the outcome of an insurance claim…the bottom line. “It’s an insurance company that administers the plan, that decides on the claim, and ultimately has to foot the bill if the benefit is granted – and that’s a conflict of interest that everyone can easily see,” said Sean M. Anderson, a University of Illinois expert in employee benefit plan policy and regulation.
4. They will find loopholes within parity laws. Mental Health Parity requires insurers to provide equal coverage for both physical conditions and mental health and substance use. Although most health plans must follow parity laws, we continue to see parity violations on a steady basis. If you suspect that your insurer has denied your insurance claim based upon a parity violation, there are steps that you can take to challenge this. See this helpful NAMI graphic for more information.
5. There is almost no risk to the insurance company in denying an ERISA (Employee Retirement Income Security Act) claim. The worst that happens, IF the claim is appealed, and IF the insured gets a lawyer, and IF the lawyer will take the case, and IF the court rules in favor of payment, is that the claim has to be paid. That’s a lot of “ifs,” and insurance companies bank on the fact that most of those “ifs” never happen. Even if they do, it doesn’t cost the insurance company any more than it would have had they decided to pay the claim in the first place. The odds are stacked in their favor. These issues are most pronounced in the area of health, life, and disability claims, and it has become nearly impossible for individuals to have these claims fairly evaluated and properly paid. As a result, insurance companies have a very strong incentive to deny claims for benefits. Click here to learn more about ERISA claims.
6. You can appeal an insurance denial, and you can win. Insurance companies are counting on you to give up. “The insurance company is going to do whatever they can to keep you from following through on a denied claim,” states Lisa S. Kantor, founding partner of Kantor & Kantor, LLP and leading expert in eating disorder claims. “They will place obstacles in your way like deliberately misinterpreting your requests for your insurance documents. Their hope is to mislead and confuse you so that you will not continue your quest to appeal the denied claim. I encourage you to find a lawyer who is knowledgeable in both ERISA and eating disorders for help in managing this overwhelming process. There are people out there who want to help so don’t lose hope!”
Gather all of your documents, bills, and receipts for out of pocket expenses, and create an appeal for your insurance denial. In your appeal letter, explain why you disagree with their decision, provide support for your claim, and attach all documentation of forms of therapy and treatment you have tried, any prior letters or documents, copies of all medical records, and written support from providers. Include letters from clinicians, doctors, treatment teams, co-workers, family and friends. Your appeal letter can be a very powerful way to demonstrate the impact your eating disorder has on your life.