How to Get Eating Disorder Treatment Coverage from Insurance Companies

Eating disorder treatment is covered by a large number of insurance policies. However, most require families and their doctors to prove that care is needed, and sometimes, care teams and insurance administrators have differing views about how treatment should work. 

While it’s stressful to push back against your insurance company, it’s often necessary. These discussions can ensure that your loved one gets the right care in an appropriate facility. Your coverage could save you thousands in out-of-pocket medical bills.

There are a few strategies you can use to help ensure your treatment is covered, but if you need to push back, there are also some helpful ways to write an insurance appeal letter.

What You Need to Get Eating Disorder Treatment Coverage

Before an insurance company is willing to help pay for care, it often requires proof of a medical condition that needs treatment.

To make your case to the company, you’ll have to acquire a few things.

A Formal Diagnosis

You may know that your loved one is struggling with body image and diet. You’ve likely seen the signs firsthand and watched them endure difficult situations. But that isn’t enough for a health insurer.

In order to begin the insurance claim process, the corporation needs to see a formal diagnosis from a medical provider, including a diagnostic code. 

To get one, take your loved one to a medical doctor for an exam. Make sure to explain to the doctor what’s going on and ask for a formal eating disorder diagnosis. 

It will also help to ensure that the code your doctor uses corresponds to an eating disorder. To eliminate as many potential complications as possible, make sure that the code appears in your loved one’s medical record. 

Referrals

Some insurance plans also require doctors to write a formal referral for a treatment program. Look up the details of your policy before visiting the doctor to ensure you leave the office with everything you need.

When you do need a referral, the primary care physician should outline what type of treatment or specialist they recommend and how long this care should last.

Your insurance company can use those recommendations to determine further coverage details.

In-Network (Or Covered) Programs

The need to file insurance claims for in-network programs depends on your insurance type.

Many insurance plans include networks of partner providers willing to work for agreed-upon prices. If you have the option to use one of these facilities, it will likely be less expensive and easier to manage, as your insurance company will have a previous relationship with the establishment.

Still, managing coverage can be complicated, even with an in-network provider. Your doctor or insurance company representative can help you with this process.

How to Use Your Benefits for Care

With a formal diagnosis, referral, and covered healthcare provider, you’re well on your way to using your benefits. But you still may need to do a few more things to ensure you’re getting the right level of coverage. 

Gather Data

When your loved one is diagnosed, your doctor should run all of these tests. Ensure you have copies of those test results handy as needed, and check your insurance policy for any additional information the company may require.

Obtain Preauthorization

Preauthorization (also called prior authorization or precertification) involves getting approval before treatment starts. It’s a standard cost-saving measure used by insurance companies.

In these cases, the company promptly examines your claim to see if it adheres to their requirements. Reviewers are often internal employees.²

Call your insurance company and ask if your loved one’s care has been preauthorized before you start care. 

Follow Up

Preauthorization status can change, which sometimes leads insurance companies to limit the care your loved one can get under your plan. For example, one family wound up paying a claim settlement of nearly $40,000 due to a disagreement with their insurance company.³

Don’t take a set-it-and-forget-it approach to insurance coverage. Keep in touch and check back often. 

Tips for Working With Insurance Companies

When your loved one needs eating disorder treatment, you’ll stay in close contact with your insurance company for an extended period. 

These tips can help the relationship work more smoothly for everyone.

Understand Your Benefits

Ask the insurance company to send you a complete copy of your policy, not a condensed brochure, with lists of what is and isn’t covered. Read it carefully, and take notes.

Think of this as your playbook for coverage, and refer to it whenever you have questions. 

Ask for Proof in Writing

Your insurance company should provide paperwork describing what is and isn’t covered. Keep all of these documents, including their case numbers, in case you have questions later.

If you ask a question over the phone and a representative agrees to make a change for you, such as initiating a preauthorization process, ask for proof in writing. The more documents you have, the better. 

Keep Good Records

With so much paperwork involved, it’s important to come up with an organizational plan for these documents.

Ask for a Case Manager

Some insurance companies assign an employee to complex cases. This person will know your loved one’s record inside and out and can be your main contact for questions and concerns. Ask if this is an option for your family.

Consider Outside Help

Experts say some families benefit from hiring an attorney.⁴ This person can ensure that your loved one’s coverage is administered correctly. Lawyers can also initiate action on your behalf if something goes wrong.

However, hiring a lawyer may not always be the best move. It can seem like an adversarial step, and it could make working with your insurance company difficult. It also comes with added expenses. 

Think carefully about all the advantages or drawbacks of this step before making a decision. 

Be Firm but Kind

Your insurance company isn’t your enemy, although you may have difficult conversations ahead. Always remain calm, polite, and focused when speaking with representatives. Remember that they are trying to help you. 

Strive to get clear, polite answers each time you contact someone. If necessary, prolong the conversation so you can get the answers you need. 

Sending Letters to Your Insurance Company

Sometimes, coverage issues become complex and complicated. Mistakes are made, and disagreements can happen. 

When this happens, you may need to send a letter to your insurance company outlining what happened, naming your preferred alternative, and informing them of your needed next steps. 

These are called appeal letters, as they appeal on your behalf to correct something you believe the insurance company got wrong or that you otherwise disagree with. Following an insurance appeal letter sample can help you ensure you say everything you want to say and maintain the tone you want to maintain.

Sample Letter for Care Initiation

Sometimes, a diagnosis and referral are not enough to secure your loved one’s care.  The insurance company may deny your original claim. 

In these cases, a letter like this may help:

My child, [name], was diagnosed with [eating disorder name] on [date] by [doctor’s name]. They had a complete workup and were found to be [percentage] underweight with the following complications: [list in bullet form].

Their doctor recommended [facility name] for their care, and they were referred on [date]. On [date], I received a letter denying their care. I object.

I am attaching their medical records and referral letter. As these documents make clear, my child meets your requirements for care based on my plan documents. A highlighted section of those documents is attached. 

I appreciate your prompt attention to this matter. You can reach me at [number].

Sample Letter for Ongoing Care

Even after your loved one is enrolled in a program, you may have coverage questions or concerns. 

A letter like this might help in these cases:

My child is enrolled in [facility name] due to anorexia nervosa. Their primary care doctor, [name], recommended residential care due to their [list symptoms, signs, and worrying conditions].

On [date], I received notification that their inpatient care would no longer be covered and that they must move to an outpatient facility. Both their doctor and I believe this will be detrimental to their health and that that movement isn’t in line with APA guidelines for care. 

I am attaching current copies of their lab test results. I am also including their referral letter from the doctor, outlining how long they should stay in residential care. 

You can reach me at [number]. Thank you for your prompt attention to this matter. 

Other Letter Types

As your loved one continues their recovery journey, they may require additional tests, extended stays at treatment facilities, or enhanced coverage. These issues could prompt you to write additional letters to the insurance company.

The National Eating Disorders Association has several letter examples to help you with various scenarios. 

What to Do Next

Insurance companies may need some time to respond to your inquiries and letters. Be persistent. Follow up on any documents you send. 

Recovery from eating disorders is notoriously difficult for both the person struggling and their loved ones. Seeing this process through takes a lot of determination, so don’t be dissuaded if you hit roadblocks. 

If you don’t get the response you want, it could be time to hire a lawyer. But the most important thing to remember is to never give up. Recovery is always possible for your loved one.