Making the decision to seek treatment for an eating disorder is a difficult decision that requires tremendous courage. Unfortunately, once you have made that decision, an even greater challenge may be getting your insurance to pay for treatment. Most clients assume that since their insurance policies provide coverage for "all medically necessary treatment", it will cover treatment for eating disorders. The truth is much more complicated.
Shocking as it may seem, all clients seeking treatment for an eating disorder should know that at some point during your stay, your insurance company will probably withdraw coverage. In a for-profit healthcare system, your insurer's objective is to deny and devalue as many claims as possible. If you know this from the outset, it may help you muster the resources to advocate for the healthcare you need and deserve.
We always recommend that before seeking treatment, you call your insurance company to verify your benefits. However, it's important to remember that the information you receive is strictly about your benefits and is not a guarantee of payment.
Your agent may suggest that the treatment facility arrange for "pre-authorization" or "pre-certification," which makes it sound as if eligibility can be determined ahead of time. In fact, in most cases, "pre-authorization" cannot be initiated until the client is admitted to treatment. Can coverage be denied within days of admission? Unfortunately, yes, and that possibility can certainly add to the stress of beginning rehabilitation. BTW it's also a huge financial risk for the treatment facility.
The first challenge is the initial review, when the treatment center's representative contacts your insurance company to determine your coverage. During that call, a utilization specialist or other agency representative will present the results of your intake interview, medical history, nursing assessment, lab work and physical examination.
It may take several days for a determination. If coverage is denied, it is usually because the insurer claims that the client does not meet the criteria for "medical necessity." But when it comes to mental health, there is little agreement on what constitutes "medical necessity," and insurance companies often give more weight to physical complications than to a history of emotional suffering. If the client's weight, labs and physical examination are normal, coverage may be denied, even if the client has severe trauma or has been purging 20 times a day. In fact, many clients may be discouraged from seeking treatment they need because they think "they're not sick enough."
Clients and their families can help by keeping track of past lab results, physical examinations and other medical procedures. During the initial intake, the client will be asked for a detailed history of their eating disorder and co-occurring conditions. The client may be understandably reluctant to share such personal information, but these details are critical to building a case for insurance coverage.
If the initial insurance review is successful, prepare for the next round. For most clients, insurance reviews will recur on a weekly basis until, eventually, coverage is withdrawn, either because the client is not recovering quickly enough, or, ironically, if they are progressing too rapidly!
Denials of coverage can be appealed. The initial appeal is usually initiated by the treatment center, which will request a "peer review" — a consultation between a Mirasol clinician and an insurance company physician. If the appeal is denied, subsequent appeals are possible, and most of them will involve additional peer reviews. A final appeal can be initiated by the client or a family member.
Playing the insurance game is daunting, but it's important to be an informed consumer to obtain coverage for the treatment you need, and also to make sure your treatment is based on accurate information. Don't be afraid to call your insurance company and ask questions! You have the right to ask them to walk you through every aspect of your benefits, and the right to understand what you have purchased for yourself or your family members. If you are shopping for a new insurance carrier or plan, make sure you ask specifically about coverage for eating disorders and mental health. You can also be empowered by calling your insurance and advocating for yourself and your needs. Insurance has the power to help individuals get the care they need, and you deserve to be informed. Don't let what you don't know impede the brave decision to seek treatment!
Director of Admissions and Utilization Review