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Getting your health plan to pay

Susan had been hospitalized twice for her bipolar disorder following a suicide attempt. She worked hard on her recovery, but she needed help. Her doctor recommended an intensive outpatient programdesigned to build healthy life skills and help prevent future hospitalizations. But her insurance would cover only a fraction of the cost. Ironically, if her mental health worsened and she had to be admitted in the hospital as an inpatient, her insurance would cover 80 percent of the cost.

The methods of insurance plans can sometimes seem arbitrary and unfair. But their purpose is to cut costs.

“The most important thing you can do is be familiar with your health plan benefits before you begin treatment,” says Chris Gabel, COO, Hollywood Pavilion Hospital in Hollywood, Florida. It’s also a good idea to get a list of the drugs the plan will cover, a drug formulary,” he says, which may also be online. Talk to someone in the member relations office if there is anything you don’t understand.

But, if your insurer denies coverage for your services or medications, you can always argue your case, especially if your doctor is doing the same thing, says Gabel. Here are some steps you can take.

Getting your health plan to pay

Prove it. To determine whether or not they will pay for services, your insurance company will decide whether the services are covered by your plan and if they are “medically necessary,” and that’s the case you and your provider must make.

Negotiate. For example, if your health plan cannot provide a psychiatrist when you need one because of long wait times, they might pay for the services of an out-of-network doctor. Or, you might have a better chance of getting an appointment if you ask your primary care doctor to make the call on your behalf, says Gabel.

Get Pre-Authorization when required by your benefits plan. Without it, the company may deny your claim. And, read the fine print.  For example, even if your plan provides for a certain number of provider visits, they may still deny payment if they decide it isn’t medically necessary, or may require preauthorization after a certain number of visits.

Stay in touch. Keep the lines of communication open. For example, if you’re in the hospital and you don’t feel ready to leave, don’t just discuss it with your doctor. Talk to your health plan representative too.

If your insurance company denies your claim

You can appeal
1.Get help from your health care provider; they are required to appeal on your behalf and explain why the services were medically necessary. They can request an expedited appeal for emergencies. Your doctor may also get you coverage for a drug not covered, or covered only as a generic, by explaining that the drug, or a brand-name drug, is necessary for your treatment.

2. Gather test results and other reports.

3. If the insurance company will not cover your services during the appeal, find out what charges would be if coverage is denied and discuss payment options with your provider.

4. Ask that a written explanation of the denial be sent to both you and your provider.

5. Make sure you and your provider meet deadlines or you will probably be denied coverage. Double-check to make sure claim forms are complete and accurate.

If your appeal fails
1. “Appeal again,” up to three times if necessary. Your chances of winning increase with each appeal.

2. Ask for an appeal review by a third party, for example your employer’s human resources department or an advocacy company that, for a fee, will help you get services covered or regain money you had to pay. Some agencies don’t charge low-income patients. (Call your state’s insurance regulator for referrals or search online for patient advocacy)

3. Even if your appeal is denied, chances are that your insurance company will agree to pay some portion of your claim.

Susan’s psychiatrist was able to convince her health plan that, based on her medical history, the outpatient program was medically necessary. They agreed to cover more of the cost by substituting three outpatient days for each one of the inpatient days covered in her plan.

The Consumer Protection Manual, published by The National Coalition of Mental Health Professionals and Consumers, Inc., is an empowerment tool for consumers and advocates giving precise information and strategies for solving problems with managed care and receiving the best mental health care possible.

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