Category: Denials Management

Parents must EMOTIONALLY advocate, be persistent, be perfect with the details both past and present of the situation (like the parents of those that can’t document for themselves) — and find the right care manager!

As we all know, they are not all created equal and these are HUMAN choices – not policy.

We are advocates for every patient, but we can only be as good as the information (tools) that is provided to us.  We know that every patient is unique and their story and medical background is as well. So what happens if there is a denial?

We will need first get the denial letter. You should also get a copy of your patients plan’s full benefits language, sometimes called the “Evidence of Coverage,” as well as the detailed guidelines that explain what the company considers medically necessary. Some companies, such as Cigna Corp. and Aetna Inc., post their medical policies online.

You will want to prep your families for denials as it is just part of the process.  However, together with you and your families we can work together to make sure that the process ends up in approval of coverage.

So, How much control do you have over denial of your mental health and substance abuse insurance benefits?

The first step you need to do in order to answer this question is to make sure you understand a variety of insurance terms.

Does your patient meet “Medical Necessity”?

• Medical Necessity is a benchmark set by insurance plans used to determine if your programs care is reasonable, necessary, and appropriate for the patient in question.

What is “Utilization Management”?

• Utilization Reviews are done as a partnership between program clinicians and insurance customer service representatives. These reviews are used as an ongoing measurement to determine what level of care is necessary for patients. The level of care needed must be congruent with accepted medical practice – scientifically proven to be effective.

Why is “Pre-Authorization” so important?

• This term has many names: prior authoriztion, pre-auth, prior approval, and precertification. This essentially means that the patient must ask for approval before checking into your program. The insurance carriers want to make sure that the patient is in need of a certain level of treatment before they agree to start paying for treatment.

When does “Step Therapy” come into play?

• Depending on a patients insurance plan benefits, it may be required that they “fail” out of a less costly therapy or drug before they can be eligible for another option.

If you are able to piece this glossary puzzle together – the answer to the above question comes quick. The only thing that has control over a denial of services for any of your patients – is the health and progress of that patient. There is nothing you can do as a substance abuse treatment program, or any behavioral health facility, to keep insurance companies from denying claims.  They are simply following the criteria and policies set down by each individual plans benefits.

What happens if there is a claim that gets denied?

There are many reasons a claim could get denied, and some of those are worthy of an appeal. It could be because of:

• The patients care needs and  benefits should be awarded the service.
• Treatment is not taking into consideration other health ailments.
• You don’t think the insurance company is following entirely under the mental health parity law.

Here is how to address an appeal:

If there is a reason to appeal – strategize a plan of attack and have a goal. Make sure you have reasonable expectations and a lot of patience!

1. Request a reason for denial from the insurance carrier,
2. Provide all necessary documentation requested by the carrier for the appeal – could be a history of medical records.
3. Stay on time! Meet the deadlines put forth by the carrier.
4. Keep following up until you have an answer.