A Few Words on Insurance Coverage
Health insurance coverage for mental health care, including treatment for mood disorders and personality disorders, etc may not be straightforward. Below you’ll find information and additional resources that may be helpful in filing claims and in securing coverage that you are entitled to—under your policy and under the law.
Insurers must treat mental health care in the same way they treat physical health care
In 2008, Congress passed an important law, the Mental Health Parity Act that requires insurers to cover treatment for mental health no more restrictively than treatment for illnesses of the body, such as diabetes and cancer. Since the passage of this law, there is increasing awareness of mental health parity.
Claims denials are too common, especially for care beyond routine office visits
Despite the legal protections afforded by the Mental Health Parity Act, insurers continue denying claims for mental health care for a wide range of reasons, including:
• Dispute regarding the clinician’s diagnosis
• Assertion that treatment should be discontinued for either insufficient progress (“it’s not working”) or for past achievement of progress (“it’s worked and therefore no longer appropriate”)
• Focus on crisis stabilization, rather than sustained care
• Determination that the care is not “medically necessary”
Also, don’t be discouraged by an insurer’s published treatment criteria. In certain cases, such criteria may not be representative of generally accepted standards of medical care or may violate the Mental Health Parity Act.
Securing a ‘Medical Necessity’ letter
Your clinician may provide a “Medical Necessity Letter” as helpful documentation in dealing with insurance claims: • Retain a copy for potential use in appealing a denial or even litigation. Note that insurers typically limit the number of appeals that can be filed and that sending a letter after a denial may be considered as an appeal— seek advice from an appeals expert to be sure.
• For guidance on these letters, see this link.
If you receive a denial after submission of a claim, you have the possibility of filing an appeal. Such appeals processes vary significantly by insurer and are often complex. Patients should seek the advice of insurance claims experts before pursuing appeals.
IMPORTANT: In any conversation you have with an insurer customer service representative, be sure to say that your questions or inquiries are NOT appeals. Insurers may limit the number of appeals and have been known to “count” inquiries as appeals already used.
Great starting points to learn about resources for dealing with insurers and mental health claims are www.dontdenyme.org, www.thekennedyforum.org and www.austenriggs.org. These sites offer information such as:
• Your rights under federal and state laws
• Links to mental health care service providers, claims advocates, lawyers and other resources
• Blog post: “Ten Steps to Ensuring Insurance Coverage for Mental Health Care”
• Blog post: “4 Steps to Maximize Appeals Success”