Eating Disorder Articles

Cover Me! Getting Your Insurer to Pay for Eating Disorder Treatment

From the Sunflower Newsletter, November, 2006

What to Do

1. First, read your insurance manual. Don't rely on a treatment center to call and get your benefit information. You need to be the expert on your insurance policy.
2. When you call the insurance company, ask to speak to a manager of benefits. Then get the name and contact information for an individual case manager. If you're not satisfied, talk to your EAP or human resources department (if you have one), or speak with your insurance agent.
3. Keep your insurance card handy. Your insurer will ask for your policy number, group number, date of birth and maybe your social security number. At this time, you can also find out how many days of treatment are covered and ask if they would consider flexing benefits. For example, some companies will take one inpatient day and convert it into two residential days.
4. It's important to remember that the information you're getting is strictly about your benefits and is not a guarantee of payment.
5. Record everything — the day, date and time of call, the name of the person you spoke with, etc. This is extremely important!
6. Ask for a copy of the guidelines your insurance company uses to determine the level of care (they're required to give it to you).
7. Meet with your family member's treatment team to determine the appropriate level of care.
8. Request that the insurance company meet your family member's level of care, which is based on the accepted guidelines.
9. If the request is denied, insist that your insurance company take full responsibility — in writing! — for your child's life, noting that they are disagreeing with the qualified experts in the field and with the approved guidelines. Feel free to ask, "Are you willing to take responsibility for denying the care that my doctor has recommended?"
10. Ask for a list of professionals and facilities that are under contract with your insurance company. If that list does not contain your preferred therapist or facility, ask if the insurance company is willing to do a single case agreement. This is a one-time contract between the insurer and the treatment the facility specifically for you.
11. Start a notebook and keep records of all communications, letters and phone calls.
12. Remember you are not asking for anything you're not entitled to. You're entitled to get the health care benefits you paid for when you or a family member falls ill.
13. If treatment is denied, appeal! Be tough and persistent! The "Insurance Issues" article describes the appeals process.

Things You Need to Know

• Eating disorder diagnosis
• Other psychiatric diagnoses
• Physiological complications of the eating disorder
• Level of recommended care (outpatient, inpatient, partial hospital, residential or intensive outpatient)
• Anticipated duration of recommended treatment
• Professionals needed and their required expertise

Tips for Fighting for Appropriate Insurance Coverage

• Record and document every phone call including names, dates, times, what was discussed and how you were advised. Put requests in writing if they are initially denied.
• Keep copies of everything.
• Be persistent in the appeals process. Many denials can be reversed.
• Call your state insurance commissioner.
• Write letters and send copies to your insurance company's CEO/President, State Attorney General, State Insurance Commissioner, US and State members of Congress, advocacy organizations, your attorney, etc. Be sure to include documentation, evidence and details.
• Get the media's attention if appropriate
• Ask your employer's Human Resources expert, your insurance agent, and/or your union representative to work on your behalf. Give them powerful statistics to prove your point.
• Know your state laws. Insurance company agents won't tell you what they are!
• Don't give up! Insurance companies want you to do just that. Be persistent!!

In the "Eating Disorders Survival Guide", you'll find out how to get treatment if you have Medicare or Medicaid, and how to get treatment that helps people with very limited resources or insurance coverage.

There are many different ways to get well. If you are really, truly ready to be well, you'll find treatment. I've helped many people with no resources develop their own treatment programs at home.

At Mirasol, when someone calls about insurance coverage, I tell them to read their insurance manuals and then to call their insurance companies and ask if they have benefits for residential treatment (remember, residential treatment and inpatient benefits are not the same). If they do, they should ask the insurance company if they would be willing to negotiate a single case agreement, and if they agree, get the name and phone number of the person you spoke with so I can contact them. If the insurer is unwilling to do a single case agreement, the client will need to arrange for payment in full before being admitted to Mirasol. We'll still complete all of the insurance company's requirements, such as pre-certification, concurrent review and billing to help secure the maximum reimbursement for our clients. We are a very small center so it's difficult for us to accept insurance in lieu of payment without a written contract with the insurance company.

Please feel free to ask me any questions you have about insurance. Mirasol only has contracts with a few insurance companies; however, there are other companies who will negotiate single case agreements with us.

Full text, NEDA's Eating Disorders Survival Guide 
Full text, NEDA's Insurance Issues Guide