Are you having trouble getting your insurance company to cover ADHD costs like mental health treatment? Join the club. When managed care entered the insurance scene a decade ago, its mandate was to contain rising medical costs. One way to do that is to deny claims, even when claims are legitimate.
The consumer backlash led to many states establishing independent review panels and requiring insurance companies to develop in-house appeal procedures. Forty-two states now have independent review boards whose decisions can override those of insurance companies. Most consumers don't even realize these review boards exist or how they can help them lower ADHD costs.
Too many people just give up when their insurance claim is denied initially. The appeals process can be long and frustrating — many people don't have the patience or time to pursue a claim no matter how legitimate.
But particularly if there's substantial money involved, the time you dedicate to appealing insurance company decisions can pay off — usually more quickly than you think. A Kaiser Family Foundation study recently found that 52 percent of patients won their first in-house appeal!
If your first appeal gets turned down, press on. The study found that those who appealed a second time won 44 percent of the time. Those who appealed a third time won in 45 percent of cases. Which means the odds are in your favor.
Mental health benefits such as those for ADHD treatment are particularly tricky because insurance companies usually have a cap on the amount of money they'll spend in a given year, or on the amount of visits they'll pay for. But in my experience, there's often some flexibility when you can document that you or your child's ADHD warrants more care than your policy usually covers.
Do your homework
Here's how to get started:
- Read your policy: Does it include mental health benefits? Which kinds of services are included? Outpatient or inpatient care? Serious or "non-serious" diagnosis?
- Know the law: Contact your local Mental Health Association to determine your state's legal requirements regarding insurance payments for mental illness. Does your state require full or partial parity? (Full parity means equal benefits for mental and physical health services.). Are parity benefits available only to patients with "Serious Mental Illness" (such as schizophrenia or major depression) or is a so-called non-serious illness such as ADHD included?
- Provide written documentation: Some insurance companies may not consider ADHD a "serious" diagnosis, but ADHD varies in degrees of severity and is sometimes extremely serious. In this case, you will need documentation to validate required services. Obtain a letter of medical necessity from your doctor and get test results showing the medical need for you or your child to receive certain services, based on the diagnosis.
- Keep good records: Remember, you'll be dealing with a bureaucracy. Keep the names and numbers of everyone with whom you speak, the dates on which you spoke, and what transpired in the conversation.
- Start early: If you can, start the appeals process prior to initiating treatment. If the doctor says your child will need to be seen once a week for a year, begin immediately to appeal your insurance company's policy of reimbursing only 20 visits a year.
- Call and ask the insurance company:
- What are the prerequisites for receiving mental health benefits?
- How many visits are allowed annually for you or your child's diagnosis? Can multiple services be combined on one day and be counted as only one day or one visit?
- Which services must be pre-certified? By whom? (Remember that pre-certification does not guarantee payment of benefits, but it is a critical start.)
- Can you or your child have a case manager? If yes, try to establish a working relationship with the case manager. If no, ask what you can do to get one.
- Be positive, polite and patient with the customer service representative. Remember that he/she is only the messenger, not the decision-maker. Even so, they are the gate keepers and can either provide you with access to a decision maker or make your life miserable, depending on how you interact with them.
- Be persistent. There are no magic bullets. Be like a dog with a bone and don't give up until you get the answer you want. If you get nowhere after several calls, ask for a supervisor or a nurse in the pre-certification department.
Remember: You do have the right to appeal if your claim is denied. Most consumers get discouraged and will not continue to pursue a claim that should or could be paid. Insurance companies count on that happening, so get out there and claim what's justifiably yours!