The information below is reposted with permission from a handout prepared by Austin Riggs Center, The Kennedy Forum, and DeBofsky, Sherman, Casciari and Reynolds.
Health insurance coverage for mental health care, including treatment for substance use disorders and a wide range of other conditions, may not be as straightforward as claims for physical health care. Below you’ll find information and suggested additional resources that may be helpful in filing claims and in securing coverage that you are entitled to —under your policy and under the law.
Insurers must treat mental health care in the same way they treat physical health care
In 2008, Congress passed an important law, the Mental Health Parity Act that requires insurers to cover treatment for mental health and substance use disorders no more restrictively than treatment for illnesses of the body, such as diabetes and cancer. Since the passage of this law, there is increasing awareness of mental health parity. Several states have passed laws reinforcing the federal legislation.
Claims denials are too common, especially for care beyond routine office visits
Despite the legal protections afforded by the Mental Health Parity Act, insurers continue denying claims for mental health care for a wide range of reasons, including:
• Dispute regarding the clinician’s diagnosis
• Assertion that treatment should be discontinued for either insufficient progress (“it’s not working”) or for past achievement of progress (“it’s worked and therefore no longer appropriate”)
• Focus on crisis stabilization, rather than sustained care
• Determination that the care is not “medically necessary”
Also, don’t be discouraged by an insurer’s published treatment criteria. In certain cases, such criteria may not be representative of generally accepted standards of medical care or may violate the Mental Health Parity Act.
Securing a ‘Medical Necessity’ letter
Your clinician may provide a “Medical Necessity Letter” as helpful documentation in dealing with insurance claims:
- At the time of filing a new claim, include a copy of the Medical Necessity Letter
- Retain a copy for potential use in appealing a denial or even litigation. Note that insurers typically limit the number of appeals that can be filed and that sending a letter after a denial may be considered as an appeal— seek advice from an appeals expert to be sure.
- Click here for a sample draft letter that your clinician can modify.
- For guidance on these letters, see https://journals.lww.com/practicalpsychiatry (July 21, 2021; p.288-295)
If you receive a denial after submission of a claim, you have the possibility of filing an appeal. Such appeals processes vary significantly by insurer and are often complex. Patients should seek the advice of insurance claims experts before pursuing appeals (Google “health insurance claims denials advocate near me” or contact us for recommendations).
IMPORTANT: In any conversation you have with an insurer customer service representative, be sure to say that your questions or inquiries are NOT appeals. Insurers may limit the number of appeals and have been known to “count” inquiries as appeals already used.
Great starting points to learn about resources for dealing with insurers and mental health claims are www.dontdenyme.org, www.thekennedyforum.org and www.austenriggs.org. These sites offer information such as:
- Your rights under federal and state laws
- Links to mental health care service providers, claims advocates, lawyers and other resources
- Blog post: “Ten Steps to Ensuring Insurance Coverage for Mental Health Care”
- Blog post: “4 Steps to Maximize Appeals Success”
In addition to the claims advocacy resources noted above, there are a growing number of attorneys who can help with unlawful claims, many of whom work on contingency. Google “health insurance claims denials lawyer near me” or contact us for recommendations.
For more information, please see “Providing a Routine Medical Necessity Letter to Improve Access to Care for Our Patients” at https://journals.lww.com/practicalpsychiatry/Fulltext/2021/07000/Providing_a_Routine_Medical_Necessity_Letter_to.7.aspx and “Medical Necessity Letters: Tips and Templates to Help Your Patients with Insurance Coverage for Mental Health Treatment” at https://www.austenriggs.org/blog-post/MedicalNecessityLetter. Both links have a page of suggested text for potential inclusion in a medical necessity letter. Click here to download a sample medical necessity letter that can be modified by a clinician.