Dealing With Treatment Denials
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The cost of health and mental health care is soaring in this country. As a result, governments and insurance companies are increasingly using managed care, which, in simple terms, is any approach to contain healthcare expenses. One of the primary cost-cutting tools of insurance companies that "manages" care is a process called utilization review. Under utilization review, a person on staff with your insurance company discusses your treatment with your mental health provider. The insurance company’s goal in reviewing your treatment is to determine two things:
- If the treatment your provider recommends is covered under your health insurance plan; and
- If your condition is "medically necessary," that is, if the insurance company feels that your treatment is essential for your physical and/or mental health.
Based on these two factors, the insurance company will "authorize" or "deny" payment for your treatment. It is often surprising to consumers when services are denied. For example, your insurance benefits may indicate that you may make 20 visits to a care provider, and your provider agrees that you need these services, but the insurance company tells you that they will not pay for your treatment anyway -- because it wasn’t medically necessary. In fact, most insurance company denials are based on medical necessity. Fortunately, insurance companies that use utilization review are required to offer an appeals process for treatment denials. If an appeal is made, consumers and their families need to be prepared to advocate aggressively for the care they need. The primary way to do this is by communicating with the insurance company’s consumer or member relations department.
This document provides information on what you can do to reverse treatment denials. It is our hope that these steps will empower you to be an effective advocate for yourself or a family member. They are divided into three stages: steps to take for the utilization review process; steps to take during the appeals process; and steps to take when your appeal is unsuccessful.
I. Steps To Take For The Utilization Review Process
The following actions are recommended to increase the likelihood that your insurance company will pay for treatment services -- and decrease the need for appeals:
STEP #1--Do Your Homework Before You Seek Treatment:
Obtain and review your health plan’s utilization review and appeals procedures as soon as you are enrolled in a health plan or, at the very latest, at the time you seek care. In addition, your insurance company should have a consumer or member relations office that can help you.
STEP #2--Obtain Pre-Authorization:
Make any calls that your insurance company requires before you get treatment. Also, inform your clinician of any calls that he or she must make, or any forms that need to be completed, when you access services. These requirements -- called pre-authorization -- should be explained in your benefits materials or written on your insurance card. Again, if you have any questions or need additional information, contact the insurance company’s member or consumer relations office. By meeting these requirements -- obtaining pre-authorization -- the company has lost one avenue by which it may deny benefits to you.
STEP #3--Provide Consent for Your Provider to Release Information:
Before utilization review begins, discuss with your provider the information s/he can and cannot release in order to obtain service authorization on your behalf. Remember, this is your personal information. Be assertive in deciding who should be allowed to see it. It is important to feel safe sharing personal information with your provider, and the law states that you have the last word on what information the insurance company receives. Companies should not request complete medical records, full session notes, or extraneous details about your personal life.
II. Steps To Take During The Appeals Process
If the insurance company refuses to pay for your treatment, despite following the steps listed above, consider taking the following actions when you and/or your provider receive a formal written notice that care has been denied:
STEP #1--Insist that your provider help you:
If your provider recommends a course of treatment, s/he is ethically bound to appeal on your behalf. Providers may be held legally liable for negligence if they do not appeal and you or someone else is hurt as a result.
STEP #2--Make sure your provider requests a special, expedited appeal for emergencies:
Emergency care cannot be put off because of standard paperwork or decision making processes. Most insurance companies provide this special appeals process, so use it when necessary.
STEP #3--Confirm with the insurance company that your services will be covered during the appeal:
If this is not possible, ask what your financial obligations would be for these services if the appeal is unsuccessful so that you may discuss other options with your provider(s), as necessary.
STEP #4--Request, or have your provider request, written notification of the reasons for denial:
Your insurance company should send both you and your provider a written explanation of the reasons care is being denied. This notice should include a description of the information required for your treatment to be approved. By providing this information in writing, it reduces the chances that there will be a miscommunication between the insurance company and you and your provider.
STEP #5--Make sure that you and your provider(s) meet all deadlines:
If your treatment is denied because either you or your provider missed a utilization review or appeals deadline, that denial is rarely overturned, even if the company agrees that treatment is necessary.
STEP #6--If you are on Medicaid, you may request a "state fair hearing" at the same time you file your appeal:
These processes vary by state. Contact your Medicaid office for details.
III. Steps To Take If Your Appeal Fails
STEP #1--Appeal again -- and again!:
Most insurance companies offer three to four levels of appeal, and each appeal will involve new people, increasing the chance that the insurance company will agree with the proposed care plan.
STEP #2--Request an appeal review by an external party:
A review by somebody who is not on the insurance company’s staff will be more objective. There may or may not be a charge to you and/or your provider for such a review.
STEP #3--Enlist the help of the ombudsman program or your employer’s Human Resources Department, if applicable:
Your state may have established an ombudsman to assist you with Medicaid problems, and your employer’s Human Resources staff should be available to assist you with any benefit problems you encounter.
STEP #4--Make alternative plans:
Even when all efforts have failed, don’t accept a flat denial of treatment services. The insurance company and your provider should come to agreement on an alternative to the originally requested treatment plan.
Page last updated: 11/12/2006