Residential Treatment for Eating Disorders: What Does Your Doctor Need to Say?

Slate.com had a great article recently by Katy Waldman talking about anorexia, and the potentially damaging narratives that even those in recovery from anorexia tell themselves.  As she writes: "[t]he anorexic impulse to lyricize one’s illness is a prescription for estrangement, for controlling and muffling the messy truths about who we are."

In the article, she calls for treatment that addresses the physical issues resulting from eating disorder: nutrition and weight restoration, rather than trying "to crack some psychological code—to unearth the mysterious psychic forces driving the illness "  

Whatever type of treatment a patient and his or her doctors want to pursue, obtaining insurance coverage for treatment of anorexia, bulimia and other eating disorders is challenging.  As with many issues with ERISA health benefits and group health insurance, what you think should work frequently doesn't.

In Connecticut, residential treatment of eating disorders, substance abuse and psychiatric illness has been difficult because there were no residential treatment programs for adolescents in the area.  There is now residential treatment for adolescents in Fairfield County, at Silver Hill Hospital, which I discussed in a prior blog post.   But, I believe we will still have many insurance companies denying coverage for residential treatment, even with a local provider.

So, what does your doctor need to say to get coverage for residential treatment of eating disorders, whether it is the "crack the psychological code" treatment or treatment addressed directly to the physical issues of eating disorders that Katy Waldman endorses?

• Typically, a doctor will tell you that:

Residential treatment is the best way for your daughter to recover

That should do it, right?  Nope.  

• What if your doctor tells you:

Residential treatment is the only way for your daughter to recover

That's got to do it, doesn't it?  The purpose of the policy is to provide treatment to cure problems, so if the treatment is medically necessary for the patient to get better, doesn't the insurance company have to pay for it?  

Still nope.  Under most health insurance policies, to get residential treatment for eating disorders, or for substance abuse treatment, or most any psychiatric illness, the doctor has to tell you:

Residential treatment is the only only way to protect your daughter from a serious risk of imminent death or serious injury to herself or others. 

I will post more in in the future about what specifically you need to do to make the best case for residential treatment for eating disorders, substance abuse treatment or other psychiatric issues, including the arcane treatment protocols that you have to follow to get benefits.  But, reviewing the policy and the incorporated treatment protocols before the claim is submitted will give you the best chance to get insurance coverage for residential treatment of eating disorders in Connecticut or in another state.   

An experienced health benefits attorney can help you get coverage for the treatment that you and your doctors think is best for treatment of eating disorders or other residential treatment.  

Denied Health Benefits under an ERISA Health Insurance Claim? Obamacare Can Help

President Obama’s health care law, the Patient Protection and Affordable Care Act (“ACA”), also known as Obamacare, requires health insurance claims to provide for external review of many types of denials of health benefit claims under group health insurance policies governed by ERISA.  An explanation of the final rules can be found here. 

For more than thirty years, ERISA health insurance plans had to provide for an internal administrative review of health benefit claim denials, a process that a claimant had to pursue before bring suit in federal court for a health claim denial.  The ACA added a significant improvement in the existing, pre-litigation review process for ERISA health plan denials.  It requires plans to offer an external review process for health insurance benefit denials, conducted by an independent third party.  The external review process is available when the denial involves application of medical judgment such as medical necessity, level of care, and experimental or investigational treatment, and whether the health care setting (out-patient, or intensive out-patient, or residential treatment) is appropriate.  I have found the process particularly useful in appealing denials of residential treatments for eating disorders or substance abuse treatment for teens.  The external review process occurs after you have exhausted the plans administrative appeals.  In addition to the claim file, the external review will consider new arguments and documents you submit with the request, so the request should be carefully completed to make it as effective as possible.  

In my Connecticut ERISA appeal practice, I have found the process particularly useful in appealing denials of residential treatments for eating disorders such as bulimia or anorexia or drug or alcohol substance abuse treatment for teens.  Connecticut does not have facilities offering residential treatment in these areas, so doctors and parents want to send teens to out-of-state programs.  

Connecticut has been a leader in implementing the ACA, so it is not surprising that Connecticut has established a good external review process.  The external review process is conducted by the Connecticut Department of Insurance.  Click here to go to the site.   A Connecticut ERISA benefits lawyer, familiar with Connecticut’s procedures, can be a big help in preparing an effective request for external review.

An important thing to remember about external review is the deadline is 120 days after the denial.  The regular time to appeal ERISA denials is either 60 days, or more commonly, 180 days, so make sure you, or your ERISA attorney, are aware of the difference.

Because of the external appeal process established by the ACA, at least with health insurance claim denials, the insurance company does not have the last word before you have to bring suit.