Friday, March 30, 2012

Fighting the Good Fight: When Insurance Won't Cover Vital Treatment

Here is a blog I wrote for my good friends at The Balanced Mind. If you haven't visited this wonderful resource, do so! The blog is a long one but it was a long "fight"!

I said that once the fight was over I would write about it. It is not quite finished, but, close enough! I was newly invigorated to write this when NBC Nightly News aired a piece recently on eating disorders and boys. The final comments included what parents should take note of and the caveat, “you may have to fight your insurance for coverage”. Well, yes. And fight we did. Here is the short version of a very long story and a two inch file.

My daughter was diagnosed with an eating disorder, and, after an evaluation, the recommendation was a 30-day partial in-patient treatment program at $1,000.00 per day. You can do the math. Our insurance company approved this treatment plan, but after careful research and discussion with the psychiatrist and psychologist, an out-patient wraparound team approach was developed. This included treatment from her psychiatrist, psychologist, eating disorder (E.D.) specialist and a nutritionist; as well as a significant commitment from family to eat every meal together for at least the first month. Linea met with her psychologist and E.D. specialist once a week. She met with her nutritionist twice a week for the first few weeks and then once a week. The insurance company covered three treatments from the nutritionist and then denied coverage. Why, you ask? It is the policy of the insurance company to cover THREE visits with a nutritionist in a lifetime. Yes, you read this correctly. 

If she had been in the in-patient treatment program, she would have seen the nutritionist once or twice a day for 30 days. The insurance company would have covered that. When asked why they wouldn’t cover the outpatient treatment from a nutritionist they replied, “We don’t have the codes.” Oh my! I was so irritated. After discussion with Linea (and her approval) I submitted an appeal to our insurance company with the following:

1. A table comparing the approved partial in-patient treatment ($30,000) with 30 days of outpatient treatment ($7,000), itemizing the costs of each treatment professional. As well, I compared the cost of 30 days of hospitalization if she did not receive treatment.

2. A letter from her psychiatrist referring to American Psychiatric Association guidelines, which state that eating disorders cannot be treated without a nutritionist.

3. A letter from the past president of the American Eating Disorders Association and her treating E.D. specialist stating the same, as well as the risk of long term treatment without the participation of a nutritionist.

4. A letter from her psychologist stating the same, and her opinion that the outpatient program would be successful, ultimately costing the insurance company less than the partial in-patient 30 day treatment program.

The appeal was denied. Reason (in case I missed it the first time): "The insurance policy provides coverage for only three lifetime visits to a nutritionist". "But", they wrote, I could "go to a second appeal". Okay, yes I will.

The second appeal, which supposedly went to medical personnel this time, rather than clerical, included all of the above and more documentation of the research on eating disorders, as well as letters that spoke of the disparity of services. Second appeal: denied. They wrote that I could talk to my Human Resources office. Okay, yes I will. By then, I was not going to let this go. After 3 months, at $110 per visit, it was adding up. More than that, it was discrimination, and it was offensive. The insurance company was overriding the treatment plan of my daughter’s doctor. Eating disorders are life-threatening. Recovery is possible with research-based treatment.

I approached the director of compensation and benefits in the HR office at my work place. Again, with permission from and discussion with my daughter, I provided him with the packet of information, and I added an additional letter. I compared treatment from a nutritionist for a person diagnosed with an E.D. to providing physical therapy to a person recovering from a stroke. THREE visits per lifetime??? I added, “I am very committed to assuring that people with mental illnesses receive the coverage and care they need as comparable to those with 'physical illnesses', even though we know that mental illnesses are a brain disorder and therefore are 'physical'. Thank you for supporting this and joining me in 'walking the talk' of social justice.”

The response from the HR director was, “My conclusion is that the nutritionist portion of the treatment plan described in (the psychiatrist’s) letter is eligible for coverage under the University’s PPO medical plan. We judge these services to be medically necessary. Our office will instruct (the insurance company) to take necessary steps to reprocess claims submitted by the nutritional therapist, and to prepare the claim system to accept future related claims that are submitted according to the same treatment plan.”

Of course, there was one more roadblock to slow us down. All the invoices had to be resubmitted, and since these were already paid for, I had to send invoices showing this. The reimbursements were processed again, one-by-one and very slowly, with checks sent to the nutritionist, who then had to run these through her business and send me a check. You can see why most people just give up. I would guess that most young people in the midst of an illness like this would not be able to fight this system. Hopefully, there are family and friends that they can ask to help and that can push back at the health care system.
The entire process took over a year to resolve. I am still waiting for the last two reimbursements. I had no idea that my HR director could assist with this. I had no idea how much effort, time and documents it would take. Please share your experiences of seeking and getting the coverage that your child deserves. Help those who can’t figure this out on their own. Together we can make a difference.


Randye Kaye said...

This is so sad. All the paperwork, time, discrimination, frustration. You rock for never giving up! We have lots of "2-inch-thick" files for my son's schizophrenia case as well.

Randye Kaye

septembermom said...

That's overwhelming what they expected of you. I applaud you for never giving up. Thanks for the information too.

Cinda said...

Thank you for the comments! Randye, you know the story well. Everytime I get frustrated I remind myself how lucky I am to have the ability to manage all of the paperwork, the ability to read and speak the language, and the stamina to keep going when it feels overwhelming. So many people have so many other obstacles. Septembermom, thank you and hopefully the information may help one other person in the struggle to get and keep good health care!

Anne Sheehan said...

Our experience is that insurance companies put every obstacle possible in your way to prevent providing coverage for mental illness. My 15 year old daughter has been in the hospital since January 18, 2013 for a suicide attempt and is being treated for major depressive disorder and an eating disorder. The doctors think she might have bipolar disorder and she is being medicated for bipolar. As our 25 days of inpatient coverage listed on our benefits statement neared the end, I started researching federal and state parity laws. Unfortunately, my company does not have enough employees to make the federal parity laws applicable. But, Virginia parity laws seemed to apply. I was told at least 15 times by our insurance company that the state parity laws did not apply. I tried to get help from our insurance broker, our firm administrator and the intensive case manager assigned by the insurance company. No one was able to help. The hospital was going to send my daughter to the state mental health facility because she was not safe to be released to us. I spent at least two sleepless nights pouring over the Internet and my insurance book. Finally, I found a section in the back of my insurance book that said exactly what the state parity laws said - a biologically based mental illness had to be covered at the same limits as medical coverage. I called the insurance company and read this information word for word from the insurance book. They told me three times that I was wrong. They said we only had 25 days of inpatient coverage and that was what my employer contracted for and the section I read only applied to outpatient coverage. I kept reading and explaining the section to them and they finally transferred me to a supervisor who promised to look into the matter and call me back. In the meantime, the hospital called and said the insurance company had given their final decision and my daughter's coverage would end in four days. The supervisor from the insurance company called me back about 20 minutes after that call and said that I was right and that my daughter would be covered under medical. I still get anxious when I think about this situation. What if I hadn't stayed up two nights researching this? What if I hadn't come across the section in the back of the insurance book? What if I hadn't been able to understand the complicated wording? The stress the insurance company put on me and my family is unacceptable. I wonder if we would have been treated that way if my daughter had a medical issue and not a mental illness? My daughter is still in the hospital, where she spent her 16th birthday. Cinda and Linea's book really touched me. Mental illness can enter anyone's life and can be devastating. I feel that my daughter and our family are just at the brink of what I expect will be a difficult journey. This experience has opened my eyes to the huge deficiencies in our country in treating the mentally ill. I can breathe a sigh of relief that my daughter now has insurance coverage, but I wonder how many families believed what their insurance companies told them?