Securing Eating Disorder Insurance Coverage from Your Insurance Company

For many people, one of the biggest barriers to eating disorder treatment is the cost. Some residential treatment programs can cost upwards of $30,000 per month, and unfortunately, companies do not always provide eating disorder insurance coverage [1]. If you are having problems getting insurance to cover your ED treatment, here are some tips for securing insurance coverage from your insurance company.

Tips for Securing Eating Disorder Insurance Coverage from Your Insurance Company

Talk to Your Insurance Company

After you receive a diagnosis and are advised on the level of eating disorder treatment you need, the first step is to find out what level of care your insurance plan will cover. The best way to find out these details is to 1) carefully read through your insurance policy to find out the benefits you’re entitled to, and 2) talk directly to your insurance company.

• Start by asking your employer for a copy of your plan. Read it thoroughly.

• Call the insurance company and ask to speak to someone who can give you your benefits. From here, get the name and contact information for an individual case manager. If you still don’t get the information you’re looking for, talk to your insurance agent or reach out to your work’s human resource department or EAP.

• Make sure you have your insurance card with you before calling the insurance company. They will need your date of birth, policy number, group plan number, and possibly your social security number.  

• Keep a record of everything that goes on throughout the entire process, from the date and time you call the insurance company to the name of the person you speak with and the information they give you about your plan. If you encounter any problems with your benefits in the future, having detailed records can help. 

Here are some questions to ask when talking to your insurance company about coverage for eating disorder care:

• Does my plan include mental health benefits? If so, does it cover residential and partial hospitalization services?

• What are my plan’s in-network and out-of-network benefits? In other words, if you seek treatment outside of your plan’s network (a facility, service, or specialist not covered by your plan), will the plan help cover the cost, or will you have to pay for treatment 100% out of pocket?

• If my plan covers out-of-network costs, how much is my out-of-network deductible and max out of pocket amount?

• What guidelines does the insurance company use to determine the level of care I qualify for? (They are required to give you a copy of these if you ask, so don’t take no for an answer!

• Can you send me a list of treatment facilities and/or outpatient providers available in my network? Additionally, find out if your preferred provider or treatment center is recommended for your in-network care.

• If your preferred provider is not listed within the policy’s network of providers, ask if the insurance company is willing to do a single case agreement (a one-time contract between the treatment facility and the insurer).

Talk to your Treatment Team

Another way to find out which treatment centers or outpatient providers your insurance plan covers is to go directly to the treatment program and ask them to conduct a benefits check on your insurance policy. Most programs are more than happy to check on your benefits for you, and many work directly with your insurance company to ensure you get the benefits you’re entitled to.

If you’ve already chosen a provider or treatment program, ask them for the service codes used when filing claims. You can then give the code to your insurance company to find out if the program or provider’s services are covered by your policy.

Additionally, if you end up going with an eating disorder provider or treatment program that does not accept insurance, ask them to give you an itemized invoice (or superbill). You can then send this itemized bill to your insurance company to seek partial reimbursement for the cost of care.

Appeal Your Denied Claims for Eating Disorder Insurance

Many times insurance companies refuse to cover advanced eating disorder treatment or stop paying for care when your weight begins to restore. If your insurance company refuses to cover your treatment or denies benefits your plan clearly entitles you to, you have every right to appeal the decision. There are two ways to challenge an insurance policy’s decision.

First, you can ask for an internal appeal. This involves asking your insurance company to conduct a full review of its decision. To file an internal appeal, complete the form required by your health insurance company. Alternatively, you can write to your health insurer, giving them your claim number, name, and health insurance ID number. Send them any other information they should consider, like a letter from your doctor or treatment program.

You can also go through the Consumer Assistance Program in your state to file an internal appeal. If your case is urgent, the insurance company is required to expedite the internal appeal process. Keep in mind that you have to file an internal appeal within 180 days (six months) of receiving notice that the insurer denied your claim.

If your claim is still denied by the insurance company, you can file an external review. This involves taking your appeal to an independent third party for review. Federal law requires that insurance companies in all states offer an external review process that meets specific federal consumer protection standards. This means you can trust that the external review process will be fair.

To file an external review, go to externalappeal.cms.gov and follow the steps to complete an external review form either online, through fax, or telephone call. If you want assistance with the external review process, you can ask a representative who knows about your medical condition (like your doctor or treatment specialist) to file the external review for you.

Finally, be persistent and don’t give up. The process of appealing a denied claim can be daunting, but your health and recovery are worth it. You may consider writing letters to your insurance company’s CEO, the State Insurance Commissioner, State Attorney General, your attorney, and advocacy organizations. Include specific evidence, details, and documentation to help further your case. You can also visit www.dontdenyme.org to learn more about your rights and get help filing an appeal.

How to Write an Appeal Letter Like an Attorney

Insurance denials for eating disorder treatment are pesky, annoying, and inconvenient. They make you work for something that you should’ve been given in the first place. But the good news is this: you can fight, and you can win.

In our office, we spend every single working day fighting against unjust insurance denials, and I’m going to let you in on a little secret. If you want to write a compelling appeal letter to your insurance company, there are a few key things you should be sure to include.

One: copies of all medical records.

Two: written support from providers, family, and friends.

Three: write your story – take this opportunity to explain the history of your eating disorder, (including documentation of all forms of therapy and treatment that you have tried) and the full impact that your eating disorder has had on your life.

Four: provide evidence-based support for your claim.

Are you wondering where you’re going to find the proper support and research to weave into your letter? The articles listed below are cited in nearly every appeal we write, and here’s why.

You Can’t Ignore the Facts

Well, insurers can, but let’s bring it to their attention anyway. It’s incredibly likely that they do not realize the magnitude of the disease and the risks associated with being unable to access appropriate treatment. Present your appeal in a way that lays out facts, research, and truths about eating disorder treatment. Explain what you need, and back it up with evidence.

They Really Don’t Know

Most insurance company employees are not well-versed in eating disorder detection, intervention, and treatment strategies. To be honest, they are not experts in this field, and might not know a thing about how eating disorders work – and they are the ones making life altering decisions about your health! Think about approaching your appeal letter as a “teachable moment.” There’s a whole world of eating disorder information out there, and the reader (and decision maker) might not know about any of it.

We Live By the Guidelines

Experts follow them, professionals follow them, therapists follow them, and dieticians follow them. Everyone in this field follows the same guidelines. The American Psychiatric Association Practice Guidelines were developed (and then reviewed) by psychiatrists, researchers, and other clinicians throughout North America and Europe. It is the standard within the eating disorder and mental health community, it’s evidence-based, and it is a significant tool in assisting clinical decision making. Insurance companies might make up their own internal guidelines, but we follow APA to a tee.

So take a look at the articles below, and consider using them in your letter. You’re already one step closer to appealing like a pro.

1. Guideline Watch Practice Guideline for the Treatment of Patients with Eating Disorders, Second Edition –http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/eatingdisorders.pdf;
2. American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders, Third Edition — http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/eatingdisorders-watch.pdf;
3. 2012 Academy of Eating Disorders Critical Points for Early Recognition and Medical Risk Management in the Care of Individuals with Eating Disorders, 2nd Edition — http://www.aedweb.org/downloads/Guide-English.pdf;
4. Academy for Eating Disorders Position Paper: Eating Disorders Are Serious Mental Illnesses — http://www.aedweb.org/index.php/23-get-involved/position-statements/89-aed-statement-on-body-shaming-and-weight-prejudice-in-public-endeavors-to-reduce-obesity-3;
5. Eating Disorders Coalition, “Facts About Eating Disorders: What the Research Shows” — http://www.eatingdisorderscoalition.org/documents/FactsAboutEatingDisorders2014.pdf; http://www.sciencedirect.com/science/article/pii/S000579670400138X;

Dealing with an insurance denial can often feel overwhelming, and might even feel impossible. Now that we’ve let you in on some of the ways we write professional appeal letters, our hope is that you feel empowered to tackle your own appeal letter and fight for the health benefits that you deserve. If things become too complex to manage on your own, you may want to consider seeking assistance from a reputable professional. In the meantime, arm yourself with knowledge and continue to fight on your path to recovery.

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References:

[1] Navigating Insurance Coverage for Eating Disorder Treatment. Center For Discovery. (2019, October 22). https://centerfordiscovery.com/blog/navigating-insurance-coverage-for-eating-disorder-treatment/.

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About the Author:

Sarah Musick is a freelance writer who specializes in eating disorder awareness and education. After battling with a 4-years long eating disorder, she made it her mission to help others find hope and healing in recovery.

Her work has been featured on numerous eating disorder blogs and websites. When she’s not writing, Sarah is off traveling the world with her husband.

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Contributor: Elizabeth Green is a Senior Associate at Kantor & Kantor. Kantor & Kantor has developed a specialized legal practice representing clients whose claims for treatment of eating disorders, and dual diagnosis (substance abuse and other co-morbid conditions) have been unfairly denied by their health insurers or benefit plan.

Contributor: Rachel Teicher, B.A. in Psychology – Kantor & Kantor, LLP.

About Kantor & Kantor, LLP: Kantor & Kantor is the largest law firm in the country exclusively representing plaintiffs who have been denied insurance benefits from life, health disability and long-term care policies. Kantor & Kantor offers no-cost consultations and is happy to provide additional support.  The firm has extensive experience with the complex appeals process and federal court litigation of ERISA matters. Kantor & Kantor is one of the few law firms in the country with a distinct eating disorder practice staffed with lawyers and other professionals experienced in the specific needs of people who have been denied benefits for eating disorder treatment.

For more information about Lisa Kantor and Eating Disorder Legal Assistance, please visit our website and our Eating Disorder blog, or follow us on Twitter (@lisaskantor).

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The opinions and views of our guest contributors are shared to provide a broad perspective on eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer a discussion of various issues by different concerned individuals.

We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.

Published September 8, 2020, on EatingDisorderHope.com
Reviewed & Approved on September 8, 2020, by Jacquelyn Ekern MS, LPC