While pushing back against your insurance company is stressful, it’s often necessary. These discussions can ensure that your loved one gets the right care in an appropriate facility. And your coverage could save you thousands in out-of-pocket costs.
Insurance Coverage for Eating Disorder Treatment: What You Need
Before an insurance company is willing to help someone pay for care, they often require proof that the person is in need of help.
You’ll have to acquire a few things to make your case to the company.
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 an insurance company.
The corporation needs a medical provider’s formal diagnosis, including a diagnostic code, in order to begin the insurance claim process.
To get one, take your loved one to a medical doctor for an exam. Make sure to explain to the doctor what’s happening and ask for a formal diagnosis of an eating disorder.
It will also help to ensure that the code your doctor uses corresponds to an eating disorder. And to eliminate as many potential complications as possible, ensure that the code appears in your loved one’s medical record.
Some insurance plans also require doctors to write a formal referral for a treatment program. It may be helpful to look up your policy details before visiting the doctor to ensure you leave the office with everything you need.
When you need a referral, the doctor should outline what type of treatment they recommend and how long it should last.
Your insurance company can use those recommendations to determine further coverage details.
This need depends on the type of insurance you have.
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 not only likely be less expensive but could be easier to manage, as your insurance company will have a previous relationship with the establishment.
Navigating in-network providers can be complicated. Your doctor or insurance company representative can help you with this aspect of the process.
How to Use Your Benefits for Care
With a formal diagnosis, referral, and covered 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
Insurance companies may require more information before approving your loved one’s treatment plan. Some insurance companies ask for: [1]
- Body weight vs. height
- Vital signs
- Laboratory test results, including hormonal and metabolic status
- Cardiac testing
Your doctor should run all of these tests when your loved one is diagnosed. Ensure that you have copies of those test results handy as needed.
Obtain Preauthorization
Preauthorization (also called prior authorization or precertification) involves getting approval before treatment starts. It’s a common cost-saving measure used by insurance companies, and 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 nearly $40,000 out of pocket 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.
You may want to put together a log of all of your phone calls and letters that includes the following information:
- When the contact took place
- Where you made contact (via phone, email, website, or text)
- Who you talked to, including representatives you spoke with on the phone
- Why you made contact
- What was the result of the conversation
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 properly. Lawyers can also initiate action on your behalf if something goes wrong.
But 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 this step’s advantages or drawbacks 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 you’re speaking with representatives. Remember that they are trying to help you.
Strive to get clear, polite answers each time you reach out. Prolong the conversation, if needed, so you can get the answers you need.
Sending Letters to Your Insurance Company
Sometimes, coverage issues become complex and complicated, and mistakes are made.
When this happens, you may need to send a letter to your insurance company in order to outline what happened, name your preferred alternative, and inform them of your needed next steps.
Different types of letters are sent for different parts of the process. Regardless, every letter should include the following:
- The date
- Your name and address
- The patient’s name
- The patient’s date of birth
- The patient’s insurance ID
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 will no longer be covered, and 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 on their recovery journey, they may require additional tests, extended stays at treatment facilities, or enhanced coverage. All of 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. It takes a lot of determination to see this process through, 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.
Resources
- Eating Disorders — Levels of Care. (2021, September). Moda. Retrieved September 29, 2022.
- Pestaina, K., Pollitz, K. (2022, May 20). Examining Prior Authorization in Health Insurance. Kaiser Family Foundation. Retrieved September 29, 2022.
- Gordon, D. (2021, Feb. 26). Despite Progress, Patients Still Struggle With Insurance Coverage for Eating Disorder Treatment. Forbes. Retrieved September 29, 2022.
- Insurance and Legal Issues. National Eating Disorders Association. Retrieved September 29, 2022.
- Sample Letters to Use With Insurance Companies. National Eating Disorders Association. Retrieved September 29, 2022.