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Background: Because few eating disorder treatment providers understand how to effectively authorize insurance coverage for treatment, many clients are denied the care they deserve. We will offer solutions for the most common legal and clinical obstacles. Using a variety of actual cases, participants will develop essential insurance authorization skills.
Fighting the Good Fight: Methods for Effectively Dealing with Insurance
Overview of the insurance authorization process.
The role of clinicians in this process.
Common problems encountered in obtaining insurance authorization.
Different types of insurance plans and their implications for authorization.
Fully-Funded
State-Funded
Self-funded
Employer benefits: Group plans/ERISA
Appeals, court procedures, evidence, remedies.
Individual Policies
Appeals, court procedures, evidence, remedies.
The Insurance Authorization Sequence
Verification of Benefits
Intake – precertification
Ongoing concurrent reviews.
Constant collaboration with the treatment team.
Doc to docs
The medical director’s verdict
If denied, consider appeal options.
If appeals fail, consider litigation.
Common reasons for Denial
Medical Necessity
Parity Laws
Medical stability
State definitions trump
Look for loopholes
Exhaustion of benefits
Know the policy
They may deny benefits included in the policy
Know the state’s involvement with mental health parity
Rigidity in what the insurer thinks treatment should look like:
Telephonic family treatment
Partial with boarding
Selectively exclude eating disorder patients
Therapeutic exposure home passes
Insurance Tricks: The Seven Deadly Fallacies
Conflict of Interest
The Rubber Ruler
Straw Man Argument
False Authority
Red Herring
Non Sequitur
Post Hoc Fallacy
Use APA Consistent Documentation
Motivation to Recover
Co-occurring Disorders
Structure Needed
Ability to control compulsive exercising.
Ability to inhibit purging.
Environmental Stressors
Geographic availability of treatment
When to Challenge Denials
APA-inconsistent standards
Structural conflicts
Logical fallacies
Plan conflicts
Legal violations
Legal Problems
Obligation to communicate
Getting the claim file
Plan discretion
Writing Appeal Letters
Internal Appeals
External Appeals
Litigation
Summary
Interactive Case Studies
Question and Answer Period
Most eating disorder treatment in the U.S. is covered by insurance. Healthcare providers in many disciplines (e.g., M.D.’s, psychologists, nurses, dieticians, etc.) must effectively interact with insurance companies in order to authorize the healthcare benefits their eating disordered patients depend upon for care.
Unfortunately, few healthcare providers have formal training in how to effectively conduct insurance authorization. When providers fail to authorize treatment, they suffer significant financial consequences and their patients fail to obtain the critical treatment to which they are entitled. Insurance authorization usually fails due to: 1- the provider’s inadequate understanding of how utilization review (UR) works, 2- lack of collaboration between the clinician and the patient, 3- inadequate clinical documentation and 4) lack of understanding the legal issues involved. Failed insurance authorization can result in unnecessary patient morbidity and mortality, exposing providers to legal and ethical issues.
This presentation will guide providers in how to best obtain and sustain insurance authorization for patient care. The most common authorization problems will be identified and solutions will be provided. Interactive case studies will be used to deepen understanding of this critical process. The three presenters offer expertise from the clinical, insurance and legal domains.
Dr. Christian obtained his Ph.D. in clinical psychology from Utah State University in 1992. His master’s thesis and doctoral research focused on obesity management. He served as a faculty member in University of Idaho’s Department of Psychology from 1992-1998 where he did research on eating disorders and the Stages of Change. He practiced clinical psychology in Logan, Utah since 1998. Dr. Christian serves as a consultant for Avalon Hills Residential Eating Disorders Program where he provides supervision and clinical program support. Dr. Christian also conducts continuing education seminars for psychologists, physicians, and other healthcare professionals.
Ms. Brown currently serves as Director of Nursing and Utilization Review at Avalon Hills Eating Disorder Treatment Program. Ms. Brown has practiced as an Intensive Care/Critical Care nurse and has worked in a cardiac catheterization lab and emergency room. She currently oversees all aspects of the nursing department as well as insurance precertifications, concurrent authorizations, appeals, external reviews, and clinical collaboration with legal counsel when insurance litigation becomes necessary. Ms. Brown has been instrumental in helping Avalon Hills build their nursing department, obtain Joint Commission accreditation, and develop a state-of-the art utilization review model.
and
Lisa S. Kantor, J.D.
Lisa Kantor has been practicing law for over thirty years, recently becoming the country’s premier advocate for patients with eating disorders who have been denied benefits by their health insurance carrier. Ms. Kantor has obtained several key victories for clients with eating disorders including cases that have changed the law in California. Partner Lisa Kantor's devotion to her work lead her all the way to the U.S. District Court of Appeals, creating one of the most influential decisions of our time, and paving the way to making treatment and recovery for various types of mental illnesses attainable.
