Working with Insurance Companies and the SystemThe current mental health care system's reimbursement policies and "managed care" guidelines make it very difficult for eating disordered patients to receive treatment. These illnesses are multi-determined, with possible physical or genetic predisposing factors, in addition to multiple psychological issues. The illness process leads to significant physiological changes requiring medical treatment in addition to psychiatric treatment but the reimbursement system does not allow for a holistic approach, wherein the costs of treatment might be more fairly shared between medical and psychiatric insurance benefits. Furthermore, some companies have very specific and inadequate guidelines for treatment, which fall far short of the current recommendations by the American Psychiatric Association (2000). Consequently, patients, families, and practitioners frequently have to fight to get the appropriate and necessary treatment.
The following suggestions may help:
1. The most important first step is to have a complete assessment. This includes a medical evaluation to rule out any other physical cause for the symptoms, to assess the impact the illness has had to date, and to determine whether immediate medical intervention is needed. See recommended laboratory tests list below. Equally important is the mental health assessment, preferably by an eating disorder expert, to provide a full diagnostic picture. Many people with eating disorders have other problems as well, including depression, trauma, obsessive-compulsive disorder, anxiety, or chemical dependence. This assessment will determine which level of care is needed (inpatient, outpatient, partial hospital, residential) and which professionals should be involved in the treatment.
2. Pursue the recommended level of care. Ask your insurance company, HMO, and health care providers for recommendations for programs or specialists.
3. Find out about local resources for treatment. See the Perfect Illusions Help & Resources for referral sources.
4. If your company does not provide a benefit for the recommended level of care (some policies have inpatient and outpatient, but no residential or partial hospital benefit), ask them to "flex the inpatient benefit." Appeal this to the medical director of the company if you are denied. Also, speak to your employer, union, or human resources department. As they pay for your coverage, they can pressure the company to provide the needed service. Have your physician or specialist who evaluated your loved one write a letter documenting the level of care needed.
5. Record the date/time/name of all your communications with the insurance company. Put your request in writing if they are initially denied. Keep copies of everything.
6. Insurance and managed care companies are governed by state laws, but most states mandate an an appeal process. Usually, you must file and "internal appeal" with the company. First, request a letter from the company stating that they have denied the coverage you are seeking. (You need this denial in writing). Also request an explanation of their appeals process. Read the membership book from the insurance or managed care company - if the service you need is clearly excluded, appealing the denial will be pointless. A letter to the medical director documenting the need for treatment and risks of not receiving it may, however, cause the company to re-examine their policy.
7. If this is unsuccessful, write to the state insurance commission and/or speak to an attorney. Provide copies of all documentation.
8. Consider getting the care recommended by arranging to self-pay, while you continue to pursue reimbursement.
9. If the insurance company approves treatment, but not in a specialized program, appeal this decision. Or, ask that the treating clinicians obtain supervision and training from experts in eating disorders. If this treatment does not result in significant improvements, ask that further treatment be provided by specialists.
10. If you have no insurance, local mental health clinics or departments of psychiatry at medical schools may be useful resources. Also, you can apply for state assistance (Medicaid) through your local Department of Social Services or for Medicare if you meet the criteria for disability. There are some research programs which provide treatment for no cost, but you must meet strict criteria. Contact your local major universities or medical schools to find any local research or studies for eating disorders. Columbia-Presbyterian has an ongoing research program with specific criteria. They can be reached at 212.543.5739 or at NY State Psychiatric Institute, 1051 Riverside Drive, Unit 98, NY, NY 10032. Email EDRU@pi.cpmc.columbia.edu. The Eating Disorder unit at Princeton University is sponsoring an inpatient study on Anorexia Nervosa. Contact them at 609.497.7790 or MclindaParisi@mcp.edu or The Medical Center at Princeton, 252 Witherspoon Street, Princeton, NJ 08540
11. Visit Help & Resources for more information about eating disorders and to promote better treatment coverage through advocacy efforts.
Recommended Laboratory Tests
15% or more below ideal body weight (IBW)