1. Introduction: How insurance companies process claims for treatment of eating disorders
a. The #1 reason claims for eating disorder treatment are denied is lack of medical necessity.
b. Medical necessity is determined by applying insurance company criteria.
c. The best way to avoid or challenge medical necessity denials is by thoroughly documenting the treatment.
2. Insurance Company Criteria
a. Why they create their own criteria
b. How they create their criteria
c. Insurance company criteria and the APA guidelines
d. Criteria varies by level of care (i.e. residential, acute, etc.)
3. How an Insurance Company's Criteria Affects The Claims Decision
a. How the criteria is applied at admission and concurrent reviews.
b. Criteria can require certain symptoms, plans of care, facility qualifications, etc.
4. Evidence‑Based Treatment Records Can Be Used to Satisfy Insurance Company Criteria
a. Evidence‑based treatment records can address and include facts which will document necessity of care by satisfying criteria
i. Treatment team plans of care (i.e. nutrition, psychological, etc.)
ii. Documenting symptoms and need for care.
iii. Co‑morbid conditions
5. Conclusion: Insurance benefits for the treatment of eating disorders are obtainable if evidence‑based treatment records provide substantial documentation of factors including the treatment, symptoms, and plan of care.
a. Evidence‑based treatment properly documented also greatly increases the ability to recover insurance benefits through subsequent appeals and litigation.
At the end of this presentation, participants should have an understanding of
- The criteria used by insurance companies to determine whether benefits are payable for eating disorder treatment;
- How insurance companies apply their criteria to determine whether benefits are payable for eating disorder treatment; and
- How providers can document their evidence-based treatment to satisfy the criteria of insurance companies and maximize the client’s insurance benefits.
Ms. Kantor is among only a few lawyers advocating for insurer reimbursement for clients with eating disorders. She has a number of significant wins, including eating disorder cases that have changed the law in California and the 9th Circuit. She is currently working with eating disorder professionals and facilities to determine what actions will change the insurance industry’s perception about care for eating disorders and what regulatory, legislative and class action litigation measures are necessary. Ms. Kantor has been a featured speaking for the Los Angeles, Orange County and San Diego chapters of the International Association of Eating Disorder Professionals.