Appealing the Denial of Mental Health Care
By Eric M. Plakun, MD, Associate Medical Director and Director of Biopsychosocial Advocacy
This article originally appeared in the Winter 2017-18 issue of the ARC News.
Many people have had the unhappy experience of being denied insurance coverage for mental health treatment they, their family, and doctor agree is medically necessary. Appealing denials can be complicated, frustrating, confusing, and difficult to navigate.
If you receive a denial from your insurance company for mental health treatment that you and your treating clinician believe is medically necessary, there are three important tools to maximize the chances for success in an appeal:
- Use the patient’s voice as a party to a binding contract
- Anchor appeals to third-party resources
- Invoke the parity law
Use the patient’s voice as a party to a legally binding contract to provide care
The contract generally supports access to medically necessary care, meeting generally accepted standards. Insist on access to the written criteria used to determine medical necessity for the treatment you are seeking and to which ones they say your case doesn’t meet.
Your voice and the voices of those supporting your treatment matter. You, your family members, and your treating and referring clinicians can write letters explaining your need for treatment based, whenever possible, on challenging the specific reasons for denial. The insurance agent who sold the policy, a benefits manager (if your insurance plan has one), or your state’s insurance review board (if one exists) may also be able to offer assistance.
Whatever actions you take, fully document all interactions you have with your insurance company or the reviewing agency—including hold times, referrals to other phone numbers, and the like. Show that you have the will and the wherewithal to stand up for your rights.
Anchor appeals to third-party resources
Research and other benchmarks to back up claims of medical necessity are helpful in the appeals process. There are instruments to guide level-of-care decisions (like access to residential or intensive outpatient programs) using objective methodology, such as the Level of Care Utilization System (LOCUS) developed by the American Association of Community Psychiatrists and used in 26 states and in multiple countries (and available online at: providersearch.mhnet.com/Portals/0/LOCUS.pdf). In addition, the American Psychiatric Association (APA) Clinical Practice Guidelines often lay out evidence-based components of treatment for many disorders. The LOCUS and the APA Clinical Practice Guidelines can provide an objective frame of reference–in fact, many insurance companies and reviewing agencies claim to use both in developing their own criteria.
Current peer-reviewed research can also anchor appeals to an evidence base for specific kinds of treatment. As you can read in the “Does Our Treatment Work?” section of our website, Riggs has organized a large body of research supporting the kind of longer-term, residential treatment we offer. Citing resources like these can help in building a case for treatment that you and your treating clinician believe to be medically necessary.
Invoke the parity law
The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that the quantitative (e.g., number of office visits, or inpatient days, etc.) and non-quantitative (e.g., hurdles like prior authorization or concurrent review) limits applied to access to mental health care be comparable to those applied to medical coverage.
For example, if a health insurance company says someone with a mental health issue cannot receive treatment unless he stops drinking, but continues to cover treatment for someone with diabetes who is not following his diet, the policy is likely out of compliance with the parity law. Similarly, if an “intermediate” level of care like residential treatment is excluded except for those meeting criteria for acute inpatient treatment, but intermediate levels of care are covered, for example, for stroke patients who no longer need inpatient treatment, but need an intermediate level of care to regain the capacity to walk, talk, and do self-care, the policy is likely out of compliance with the parity law.
If you believe a denial does not comply with the parity law, raise this concern in the appeal. You may wish to speak with an attorney familiar with parity law violations or your State Attorney General’s Office.
While the tools outlined here do not address the larger issue of full implementation of the mental health parity law (it may take class action lawsuits to do this), I hope they are helpful for individuals appealing insurance denials for care that they and their treating clinicians believe to be medically necessary. Remember, even though the process is daunting, don’t give up; the right tools, support, and persistence can make a difference.