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Strategies to Counteract Insurance Denials

For most clinicians, eating disorders patients, and families, insurance is a confusing game for which few have any training, according to members of a panel discussion at the NEDA meeting in Los Angeles in October. The panelists included attorney Lisa S. Kantor, Esq., of Kantor & Kantor LLP, Northridge, CA; Stacey Brown, Director of Nursing and Utilization Review and Dr. David Christian, Clinical Psychologist and Consultant, Avalon Hills Eating Disorders Treatment program, Logan, UT. Lisa Kantor litigates insurance coverage issues for eating disorders across the country. At Avalon Hills, Stacey Brown oversees all cases of insurance pre-certification, appeals and reviews, and David Christian trains therapists to document patient care in ways that maximize insurance authorizations.
Panel members told the audience, “How you play the game can help or hurt you and the outcome, and the more clinicians know about the insurance game, the more effectively they can play it.” In fully funded plans, the insurer has complete governing power until a claim goes to an external review. A state-funded plan is often governed by different state laws, and fighting a rejected claim often requires litigation, said panel members. Self-funded plans, which operate under ERISA (the Employee Retirement Income Security Act) often do not have an external appeal option. ERISA also imposes higher-than-marketplace standards on insurers. For example, it sets forth a special standard of care upon a plan administrator, namely that the administrator “discharge” his or her duties in respect to discretionary claims processing “solely in the interests of the participants and beneficiaries” of the plan. This factor underscores the importance of accurate claims processing, and demands that administrators “provide a full and fair review” of claim denials.”
 

 

How to fight for coverage of eating disorder treatment

Eating disorders can be both medically and financially devastating. The National Eating Disorders Association says as many as 10 million women and 1 million men in the U.S. battle anorexia or bulimia, and another 13 million more struggle with binge eating or an obsession with dieting. Worse, kids as young as 8 and 9 are being diagnosed with eating disorders and adolescent girls are still the No. 1 demographic for developing an eating disorder.
 

What to Expect from Your Pre-Existing Condition Insurance Plan Application

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Working With Insurance Companies to Obtain Coverage

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Insurance Coverage: Tips for Navigating

Eating disorders, particularly anorexia and bulimia, are usually covered by health insurance, partly as a result of the "parity law" now in effect in California, but figuring out exactly what the coverage is can be confusing. The parity law states that certain mental health disorders, including anorexia and bulimia, will have the same maximum co-payment as those in the general medical plan. This short guide will give you some basic information to help you get the benefits to which you are entitled and also to make decisions about maintaining insurance coverage for the future.

 

Local Mental Health Insurance Referral

 

Insurance Help Links

The following are helpful websites about insurance information and coverage for eating disorders:
National Eating Disorders Association (NEDA): Get Help Today
Association of Anorexia and Related Eating Disorders (ANAD): Insurance Issues

 

 

Example of a Follow-up Letter from Parents

 

Example of a Letter from a Physician

 

Example of an Appeal Letter From Parents

 

The Insurance Appeal Pack

 
In addition to a letter and many forms required by the insurance company, include the following:
 


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