Dr. Plakun’s 4 Tools to Maximize Insurance Claim Appeal Success
By Eric M. Plakun, MD
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 four 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
- Reference Judge Joseph Spero’s verdict in the Wit v. UBH/Optum case and what the verdict says about restrictive access to care criteria that focus treatment on the limited goal of crisis stabilization
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.
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 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. In addition, the American Psychiatric Association (APA) Clinical Practice Guidelines often lay out evidence-based components of treatment for many disorders. Both methodologies 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. Riggs has organized a large body of research supporting the kind of longer-term, residential treatment we offer, available online: www.austenriggs.org/does-our-treatment-work. Citing resources like these can help in building a case for treatment that you and your treating clinician believe to be medically necessary.
The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that the quantitative (e.g., number of office visits, or inpatient days) 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 medical issues, 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.
Below are selected quotes and highlights from the verdict:
- “Having reviewed all of the versions of the Guidelines that Plaintiffs challenge in this case and considered the testimony of the witnesses addressing the meaning of the Guidelines, the Court finds, by a preponderance of the evidence, that in every version of the Guidelines in the class period, and at every level of care that is at issue in this case, there is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions.”
- “[I]n each version of the Guidelines at issue in this case the defect is pervasive and results in a significantly narrower scope of coverage than is consistent with generally accepted standards of care.”
- Effective treatment requires treatment of the individual’s underlying condition and is not limited to alleviation of the individual’s current symptoms.
- Effective treatment requires treatment of co-occurring behavioral health disorders and/or medical conditions in a coordinated manner that considers the interactions of the disorders and conditions and their implications for determining the appropriate level of care.
- Patients should receive treatment for mental health and substance use disorders at the least intensive and restrictive level of care that is safe and effective–the fact that a lower level of care is less restrictive or intensive does not justify selecting that level if it is also expected to be less effective. Placement in a less restrictive environment is appropriate only if it is likely to be safe and just as effective as treatment at a higher level of care in addressing a patient’s overall condition, including underlying and co-occurring conditions.
- When there is ambiguity as to the appropriate level of care, the practitioner should err on the side of caution by placing the patient in a higher level of care.
- Effective treatment of mental health and substance use disorders includes services needed to maintain functioning or prevent deterioration.
- Appropriate duration of treatment for behavioral health disorders is based on the individual needs of the patient; there is no specific limit on the duration of such treatment.
- The unique needs of children and adolescents must be taken into account when making level of care decisions involving their treatment for mental health or substance use disorders.
- The determination of the appropriate level of care for patients with mental health and/or substance use disorders should be made on the basis of a multidimensional assessment that takes into account a wide variety of information about the patient.