Insurance Coverage and Eating Disorder

Five Tips to Get Your Insurance Company to Pay Claims for your Eating Disorder Treatment

Proper treatment for eating disorders is necessary for long term recovery but such treatment is often thwarted by insurance companies denying claims for necessary treatment. The key to getting your insurance company to pay claims for eating disorder treatment is to know your rights. Here are five tips to help empower you to challenge denials of claims for eating disorder treatment.

Tip No. 1: Obtain a Copy of Your Insurance Policy

If you do not know your health coverage, you do not know your rights and you do not know whether your insurance company was correct in denying benefits for treatment. If you educate yourself about your health coverage, you can challenge the insurance company when they deny benefits.

To know what health coverage you have, request a copy of your health plan. If you have health coverage through an employer, request a copy of the plan from your Human Resources Department or check the employee portal. If you have health coverage through a privately purchased insurance policy, such as a policy purchased through an insurance exchange, telephone or write to your insurance company and request a copy of the insurance policy.

Tip No. 2: Read Your Insurance Policy

A health insurance policy can be confusing. Here are specific provisions to look for which often relate to claims for eating disorder treatment:

  • Precertification penalty for not asking for precertification before admission to treatment. The penalty could be a dollar amount, i.e. $500 penalty applicable to any claims payment, or the penalty could be a denial of the entire claim.
  • Proof of loss or deadline to submit claims. For out-of-network claims you may submit on your own, this will be the deadline for you to submit claims.
  • Statute of limitations or legal action or limitation of action. This is the deadline to file a lawsuit.
  • Number of appeals and the time frame to submit second level appeal. The policy may provide up to two appeals plus an external appeal. The policy will provide the deadline for submitting each appeal.
  • Residential Treatment Center definition may include requirements such as: admitted by a physician, licensing requirements, or exclusion of wilderness treatment programs.
  • Exclusion for residential treatment or nutritional counseling for eating disorder patients. With few exceptions, these exclusions are invalid based on federal law.
  • Medical necessity or medically necessary definition often includes language such as “generally accepted standards of medical care,” which include American Psychiatric Association (“APA”) Guidelines.

Tip No. 3: Submit Your Claim.

If your treatment provider does not submit your claim, you will need to submit the claim to the insurance company. Your insurance policy will explain the process and the mailing address for submitting claims. Send the insurance company’s claim form completed with all information requested and send a completed authorization form permitting you to submit the claim if you are not the patient. These forms can be found online for specific insurance companies. Send the claim by certified mail, confirmed receipt. Keep copies of everything that is sent.

If your treatment provider submits the claim, make sure you have a copy of what was sent and check your health insurance account online to confirm the claims are received.

Tip No. 4: Receive Written Notice of the Denial.

The insurance company is required to send a written notice if it denies your claim, generally within 30 days. A denial can be in the form of an Explanation of Benefits (commonly called an “EOB”). Do not ignore these notices as they give you important information about why the claim was denied and your next step to appeal. If you do not receive notice of the denial, write or call the insurance company until you receive a denial.

If the claim was denied based on lack of medical necessity, send a written request to the insurance company asking for the guidelines or criteria that were used to deny the claim.

An underpayment – the insurance company does not pay enough on a claim – is a version of a denial.

The insurance company may not deny the claim outright but may instead ask for more information, i.e. authorization, medical records, claim numbers, etc. If you do not provide the requested information, the insurance company could deny the claim simply because the requested information was not submitted.

Tip No. 5: Appeal the Denial.

Providers or patients can appeal health claim denials. There are three ways to appeal: expedited (must show medical need for expedited basis), written (my recommendation), or telephone call (call insurance company and say “I am appealing this denial”). An expedited or written appeal is recommended because a telephone call may not be noted properly by the insurance company.

Your written appeal should include a letter explaining why you disagree with the denial, treatment records demonstrating medical necessity (if that was the basis for denial), and a letter from providers supporting the patient’s need for the requested treatment. Sign and date the letter, keep copies of everything you send with the appeal, and send by certified mail or other confirmed mail delivery.

Generally, first appeals are due 180 days from the date you received the denial. Second appeals can be due as early as 60 days from the date you receive the denial. Mail the appeal on time.

An appeal can change the course of your claim. Two recent court decisions emphasize the importance of sending provider letters in support of your appeal to prove medical necessity. In Katherine P. v. Humana Health Plan, Inc., No. 19-50276, __F.3d__, 2020 WL 2479687 (5th Cir. May 14, 2020), the appeals court reversed a decision against the patient because the appeal letters of the patient, her mother, and the treating physician all described the patient’s past failed treatment attempts. In Michael P. v. Blue Cross and Blue Shield of Texas, et al., No. 2:17-CV-00764, 2020 WL 2309584 (W.D. La. May 8, 2020), the court ruled that Blue Cross was wrong to deny a claim for eating disorder treatment and the court quoted from the treating physician’s letter send in on appeal which stated that the patient required the treatment for her safety.

With knowledge of your rights, you can maximize your health insurance coverage and obtain benefits for eating disorder treatment.

By Elizabeth K. Green, Kantor & Kantor LLP, November 2020