One of the most practical and informative sessions at the recent NEDA (National Eating Disorders Association) conference in Hollywood, CA, was a session called "Working with Insurance Companies for Care: Guidelines for Providers and Families.
The all-star team of experts was composed of Lisa Kantor, JD, of the Northridge, CA law firm Kantor & Kantor LLP (Kantor successfully brought suit against Blue Shield of California in a recent high-profile eating disorders-related U.S. Court of Appeals case); Stacey Brown, RN, director of nursing and utilization review at Avalon Hills in Logan, UT, and David Christian, Phd LP, clinical psychologist at Avalon Hills and insurance maven. The speakers guided the audience through the Byzantine process of obtaining and keeping insurance coverage for healthcare for the eating disordered individual. Judging from the packed room and the barrage of questions, it was clear that dealing with health insurers is one of the most difficult and frustrating issues facing patients and their families today.
Brown described the process of wrangling with insurers, who rarely understand the disease and usually are reluctant to pay for treatment as a "marathon, not a sprint," which requires constant attention, meticulous documentation, persistence and fortitude.
Among the tips I gleaned are:
• Have your entire health insurance policy on your computer for easy access and so you can email it to care-givers. Remember that policies are revised every year.
• Keep narrative notes of every conversation with your insurer, including the date and who you spoke to. Document, document, document.
• Make sure your side of the story gets told.
• The most common reason for denial of coverage is lack of "medical necessity." Very often states have their own definition of medical necessity that will trump an insurer's definition. Study up on your states guidelines.
• Clinicians, especially on the residential treatment side, often are not trained to help patients with insurance issues and don't know what info they need to get treatment authorized. So it's up to you to do your homework and inform them.
• If you end up in a legal fight, your lawyer can only make your case as good as the information you give her/him.
• Remember that there is an inherent conflict of interest in your situation: insurers write and interpret their own policies. Confront capricious interpretations of policy.
• The burden is on you to show that an insurer's standards for medical necessity aren't consistent with "best practices."
• Insurers use poor measures of recovery. Point out when their standards aren't consistent with best practice.
• Insurers will cite false authorities. Check to see if their "authorities" are true eating disorders experts and what their biases might be, based on previous cases.
To view the more detailed PowerPoint presentation of the session by Brown, Christian, and Kantor, click here. As Christian told the audience at the end of the session, "The message is: document, document, document, and be ready for a fight."
Nutritionist Marcia Herrin and Nancy Matsumoto, co-authors of The Parent's Guide to Eating Disorders, Gūrze Books. Marcia is also author of Nutrition Counseling in the Treatment of Eating Disorders.