Trying to getting insurance coverage for eating disorders is a confusing and frustrating experience for many patients, families and treatment providers. Several factors play into the difficulties. These include:
The high cost of treatment
Outpatient treatment usually involves sessions with a registered dietitian and a therapist or psychologist on a weekly basis, as well as regular appointments with a medical doctor and/or psychiatrist. This can easily add up to between $500-1,000 a month. Each level of care beyond that, which include intensive outpatient, partial hospitalization (sometimes called day treatment, residential and intensive inpatient) only increases the cost.
Disagreements on the length of treatment
Full recovery from eating disorders can take years. This may include months of residential treatment. Treatment professionals want to keep patients in a treatment setting as long as possible in order to help stabilize behaviors, medical status and to give the patient a chance to learn and practice new coping skills.
Insurance companies, while wanting the patient to recover, often want to keep them in treatment only as long absolutely necessary.
Treatment is needed before medical signs show up
Lauren Smolar, director of the National Eating Disorder Association Helpline states that “many people are trying to do the right thing by reaching out for help and get treatment but find that insurance companies are not willing to pay for treatment until there are significant medical consequences.”
She goes on to say that “unfortunately it seems that insurance companies do not see the value of preventative care with eating disorders.”
The complex nature of eating disorders
Bulimia, anorexia and binge eating disorder involve emotional, medical, nutritional and neurological factors. This makes treatment more expensive and recovery a long-term process. Additionally, it make assessing progress very difficult. A patient may make progress nutritionally but still have significant emotional setbacks.
Or, she might be feeling less depressed but still struggle with strong urges to binge and purge. This complexity makes it difficult to assess and agree upon treatment plans and level of care.
Deception and dishonesty
A patient may be externally cooperating with treatment but be secretly still using behaviors. This can result in family members, treatment professionals and insurance providers to have different perspectives on progress and treatment planning.
Mistrust between everyone involved
Patients who are not motivated don’t trust treatment providers, insurance providers may not trust that treatment teams are being honest about patient progress, and treatment teams may question whether insurance companies truly want what’s best for the patient or are more concerned about the bottom line. All of this makes communication difficult, tense and sometimes antagonistic.
So, how do those attempting to advocate to insurance to cover treatment for eating disorders effectively work with insurance carriers? I spoke with Chelsey Sorensen, a utilization review specialist with Castlewood Treatment Centers in St. Louis, Missouri. She provides a great deal of information on getting better coverage for treatment for eating disorders.
ED Hope: What information do insurance companies take into account when considering coverage for eating disorders?
Chelsey: When obtaining initial authorization for eating disorders, insurance is, of course, looking for medical instability as a result of eating disorder behaviors. However, client’s labs and vitals do not always reflect the abnormalities which necessitate RTC treatment.
ED Hope: So what do you do then?
Chelsey: When a patient or client is generally medically stable, it is important to initially demonstrate how the eating disorder has interrupted their daily living. Whether that be school, work, or family life. Once a client is admitted into residential with an initial authorization, it is keeping them in the RTC environment that can be difficult in terms of insurance.
With 24hr supervision and care, it is somewhat easy to interrupt the binge/ purge cycle as bathrooms and cabinets are all locked. So, insurance can be quick to reflect they have not binged and purged in a week, they must be ready for a lower level of care.
ED Hope: How do you respond to companies pushing for a lower level of care?
Chelsey: When obtaining on- going authorizations for clients struggling with eating disorders, I find it incredibly effective to give the insurance company a detailed, upfront treatment plan and trajectory before stepping down to a lower level of care.
By giving the insurance an end date, it makes them feel like they are authorizing to an end point, versus a never-ending treatment. Of course, the treatment plan is subject to change as client’s progress through treatment.
ED Hope: What is the role of utilization review staff in a treatment setting?
Chelsey: It is my job to work with the treatment team and the insurance company to advocate for the client and maximize their length of stay in treatment to promote the time needed to heal and recover.
Do your homework
Unfortunately, high medical costs and insurance coverage are a reality in today’s culture and economy. And eating disorders require intensive and complex care. Those struggling with an eating disorder as well as professionals providing care need to do some research in order to get the best coverage possible. Here are some things to keep in mind:
- Check the insurance companies’ website. Not every website lists the details of their treatment but it is important to find out what the company policy toward eating disorders treatment is.
- Find out about state and federal policies that may affect how mental health care is covered by insurance. The Mental Health Parity Law signed by Congress in 1996 is one such example. Another is the law passed this past summer in the State of Missouri that specifically requires insurance companies to consider the mental health aspects of eating disorder and not just medical status, in evaluating care needs for patients.
- Collaborate with others – when working toward better care for eating disorders, treatment centers and professionals who may be “competing” in one sense need to work together and share information in ways that result in healing and prevention of eating disorders.
NEDA’s Lauren Smolar also emphasizes the importance of having advocates.
Specifically, she recommends that client ask their professional teams to talk with insurance providers and enlist their help in advocating for treatment.
“Learn about the appeal process. Just because you receive a denial letter doesn’t mean you give up.
Professionals can advocate for you and appeal any denials by the insurance company and communicate why they believe treatment is medically necessary.”
Finally, I would highly recommend reading the article “5 Things Everyone with an Eating Disorder Should Know About Their Insurance” by Joanna Kay (http://proud2bme.org/content/5-things-everyone-eating-disorder-should-know-about-their-insurance) and check out the Insurance Resources page at the National Eating Disorder Association’s website: http://www.nationaleatingdisorders.org/insurance-resources
About the author: Travis Stewart earned a Master of Arts in Counseling (2001) and a Master of Arts in Theological Studies (2003), both from Covenant Seminary in St. Louis, MO. Travis is a Licensed Professional Counselor in the State of Missouri and a writer for Eating Disorder Hope and Addiction Hope.
The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer 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.
Last Updated & Reviewed By: Jacquelyn Ekern, MS, LPC on November 23, 2015
Published on EatingDisorderHope.com