25 Sep Effective Appeals
Patients seeking treatment for mental health diagnoses often struggle to utilize their insurance coverage for their treatment. Although mental health coverage has grown over recent years, it can seem impossible to receive coverage for mental health claims even on the best policies. According to a survey reported by JAMA Psychiatry in 2013, 29% of mental health patients will receive a denial for medical necessity versus 14% of patients with medical claims, despite Mental Health Parity Laws. Sadly, medical necessity is one of many denial reasons that can be used to deny coverage.
The services could have been pre-certified as being medically necessary, treated the diagnosis in question, and billed correctly, and the insurance company still finds fault. Maybe they suggest that the services were not necessary, that the record of services do not meet their guidelines, or the servicing location doesn’t meet some policy hidden in the booklet. How do you get around these denials? To those involved, the provider and the patient, these denials are clearly wrong, and not to mention very frustrating. Understanding the lingo of the insurance companies is generally beyond the scope of the average person, making the process even more difficult. Although many denials can be resolved over the phone with the right information, there are many denials that will go through multiple levels of appeal.
Every written appeal is different, as every patient is unique in their treatment need, policy guidelines, and many other factors. To create an effective argument, certain steps should be taken to protect the patient and provider, such as:
• a complete verification of benefits
• pre-certifying the services
• proper documentation of services
• billing requirements of the payer
• record of all communication with the payer
Some or all of this information may come into play when a denial is issued by the insurance payer.
Member appeals are often more effective than provider appeals, simply for the fact that the member is the payer’s customer. As a member, you can appeal with both a logical, facts based argument as well as the emotional argument to prove that the services were necessary enough to warrant that certain guidelines be waived. As a provider, the argument needs to be supported by facts and logic. You will also be required to provide complete records to support the claims you are making. Although appeals can be a lot of work, it is worth it in the end.
Mental health disorders are just as concerning as medical disorders. You would expect coverage for the triple bypass patient, and so you should also expect coverage for the patient suffering from suicidal thoughts. Both patients are at risk of death, and both deserve treatment in order to move forward with a healthy, happy life. As a patient or as a provider, don’t be afraid to ask as many questions as necessary when that denial EOB (Explanation of Benefits) comes to your mailbox. You never know when the right question will give you the key to overturning the denial.