Options for when insurance benefits and appeals are exhausted

Accessing care is directly tied to the kind of health insurance a patient has. While it can be time- consuming to fully understand the extent and limits of benefits available through a particular insurance plan, some basic approaches can help in both the short and long run to take full advantage of all available options. This checklist is intended to help get the patient or patient’s advocate in this regard organized.

  √  Get organized; prepare to be persistent, assertive, respectful, and rational.

  √  Read the patient’s complete health insurance policy to understand the contracted benefits.

  √  Get a logbook to document all conversations with insurers and care providers; record names, dates, and notes about all conversations.

  √  Call the insurer to discuss benefits options and find out about levels-of-care criteria the patient must meet for eligibility.

  √  Ask insurer what authorizations are needed to access care that will be reimbursed.

  √  Assist the patient in obtaining a full psychological and physical assessment from qualified providers experienced in treating bulimia nervosa.

  √  Communicate with key caregivers to devise a treatment plan, identify the names of the key caregivers and their roles, and define communication expectations for progress reports.

  √  Obtain letters of support for the treatment plan from caregivers that you can show to the insurer as needed.

  √  Present the treatment plan to the insurer.

  √  Enlist support from other family members or friends; find out how and when they are available to help.

  √  Assist the patient in entering treatment.

  √  Follow up about insurance once treatment begins to ensure reimbursement is occurring.

  √  If claims are denied for treatment, you may wish to file an appeal using the documentation you have collected, and make your argument reasonably. If an initial appeal is denied, you may wish to file at the next level. Treatments that have some clinical research evidence to support their use may be more convincing than requests for treatment for which no clinical research evidence is available.

  √  Continue treatment during the appeals process. Appeals can take weeks or months to complete, and health professionals and facilities that treat bulimia nervosa advise that it’s very important for the patient’s well-being to stay in treatment if possible to maintain progress in recovery.

  √  Clarify with the insurer the reasons for the denial of coverage. Most insurers send the denial in writing. Claims advocates at treatment centers advise patients and families to make sure they understand the reasons for the denial and ask the insurance company for the reason in writing if a written response has not been received.

  √  Send copies of the letter of denial to all concerned parties with documentation of the patient’s need. Claims advocates at treatment centers state that sending documentation of an appeals request to the medical director and the human resources director of the company where the patient works (or has insurance under), if applicable, can help bring attention to the situation. Presenting a professional-looking and organized appeal with appropriate documentation, including an evidence-based care plan, makes the strongest case possible. Initial denials are often overturned at higher appeal levels because higher-level appeals are often reviewed by a doctor who may have a better understanding than the initial claims reviewer of the clinical information provided, especially well-organized, evidence-based documentation.

  √  Ask the insurer what evidence-based outcome measures it uses to assess patient health and eligibility for benefits. Some insurance companies may use body mass index (BMI) as a criterion for inpatient admission or discharge from treatment for bulimia nervosa, which is not a valid outcome measure for bulimia nervosa. This is because patients with bulimia nervosa can have close to ideal BMIs when in fact they may be very sick. Thus, BMI does not correlate well with good health in a patient with bulimia nervosa. For example, if a patient with bulimia nervosa was previously overweight or obese and lost significant weight in a short time frame, the patient’s weight might approach the norm for BMI. Yet, a sudden and large weight loss in such a person could adversely affect his/her blood chemistry and indicate a need for intensive treatment or even hospitalization.

  √  Ask that medical benefits, rather than mental health benefits, be used to cover hospitalization costs for bulimia nervosa–related medical problems. Claims advocates advise that sometimes claims for physical problems, such as those arising from excessive fasting or purging, are filed under the wrong arm of the insurance benefit plan—they are filed under mental health instead of medical benefits. It’s worth checking with the insurance company to ensure this hasn’t happened. That way, mental health benefits can be reserved for the patient’s nonmedical treatment needs like psychotherapy. Various diagnostic laboratory tests can identify the medical conditions that need to be treated in a patient with bulimia nervosa. Also, if a patient has a diagnosis of a coexisting mental disorder (also called a dual diagnosis), and if the insurance company considers that diagnosis more “severe” than bulimia nervosa, the patient may be eligible for more days of treatment.

  √  Ask the insurer whether it will “flex the benefit.” Flexing benefits means the insurer applies one type of benefit for a different use. For example, medical benefits might be “flexed” to cover some aspect of mental health treatment—usually inpatient treatment. Or inpatient benefits might be flexed (traded) to substitute intensive outpatient care for inpatient care—for example, 30 inpatient days for 60 outpatient intensive benefit days. Substance abuse (also called chemical dependency) benefits might be traded for additional benefits to treat the eating disorder if the beneficiary thinks he/she will never need the substance abuse benefits available under his/her coverage.

  √  The clinical rationale for doing this is that if bulimia nervosa is not treated appropriately from the outset, the insurer risks incurring additional and higher costs for patient care in the future because further hospitalization and treatment may be needed. By flexing inpatient medical benefits or trading inpatient days for outpatient days to obtain more days of mental health treatment, future and possibly higher healthcare expenses might be avoided. While insurers are not obligated to do flex benefits, they may respond to a sound, logical argument to do so if it makes good sense from both a business and patient care perspective in the longer term. If you can support this argument with doctors’ recommended treatment plan and clinical evidence from practice guidelines and an evidence report, the insurer may agree.

  √  If the patient is employed or in a union, consider asking the employer (or its human resources manager) or union representative to negotiate with the insurer about aspects of the coverage policy that seem open to interpretation. As a client of the insurance company, the employer is likely paying a lot of money to provide benefits to employees (even when employees pay part of the insurance premiums). Because insurance companies want to maintain good business relationships with their clients, the employer may have more influence than the patient alone when negotiating for reimbursement. Many patients or families of patients are afraid or embarrassed to discuss bulimia nervosa with an employer. Remember that legally, a person cannot be fired and insurance cannot be dropped solely because of having bulimia nervosa (or any other health condition).

  √  Negotiate with the treatment center about the cost of treatment. Our survey of treatment centers indicates that some treatment centers have a sliding fee scale and may adjust the treatment charges or set up a payment plan for the patient for the patient’s out-of-pocket costs.

  √  Discuss with the insurer how existing laws and clinical practice standards affect your situation.

  √  Educate yourself about how your state’s mental health parity laws and mandates apply to the patient’s insurance coverage. Also ask the insurer if it is aware of guidelines like the American Psychiatric Association’s clinical guidelines for treating eating disorders at http://www.psych.org/psych_pract/treatg/pg/eating_revisebook_5.cfm and ask what role the evidence plays in the decision about benefits. As a last resort, some patients or their advocates may also contact the state insurance commissioner, state consumer’s rights commission, an attorney, the media, or legislators to bring attention to the issue of access to care for bulimia nervosa.