National Eating Disorders Association

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blaze627
Your experience with insurance appeals during treatment

Hopefully you can help. I'm trying to understand this situation: I was told that every few days during treatment, your insurance company can stop your coverage because it needs an update from the facility to determine if the treatment is still "medically necessary."

Has anyone had experience with this process? Please correct me if I'm wrong, but it sounds like your two options are:

1. Stick with the treatment while they sort out the paperwork - this can last days. Best case: you pass the appeal and only have to pay insured rate for past days (until next denial in a few days). Or if your insurance rejects it, you are on the hook for the full, non-insured daily rate during those days you went to treatment and waited. On top of that, you now officially know that you have no insurance coverage for treatment.

2. You decide not to take that risk and basically stop treatment during the wait period. If you pass the appeal, you return. Sure, you won't be on the hook for full price because you left the program while waiting for insurance to be sorted out. But treatment is going to be super stressful and far less effective if you're constantly stopping for days and dealing with the uncertainty of future treatment.

I would really appreciate hearing about your experiences and any advice.

iwanttolive
blaze627

Hi. I am glad to hear you are trying to get help for your eating disorder. It is so frustrating with insurance companies. I have state insurance and if I go to a medical hospital that has an eating disorder unit I don't have to deal with all that stress as the hospital accepts the state insurance. Private hospitals are different and make a stay very difficult at times as the are constantly reviewing your case and you never know when you will no longer be covered. I don't know what to say to help you other than that. I am sorry it is so stressful when all you want is to get help to get better. I hope what I said was helpful. Don't give up. Keep trying and I wish you the best. And yes, it is unfair and stinks. Best of luck with your recovery.
iwanttolive

Sahara
Insurance

Hi. I am right now going through insurance problems as well. I am currently two months into a relapse and was medically diagnosed (heart issue caused by the eating disorder) at the hospital just over a week ago. I was doing outpatient at the time. So, my doctor now wants me in residential, but my insurance company is sayingI only need partial hospitalization. What's strange is that due to the heart issue as well as the need to break symptom use, I meet medical requirments for residential treatment. The insurance company does cover residential, but now it is saying that I only needs partial hospitalization'..which they just so happens to NOT COVER under their policy. UGH!!!! They will will cover intensive outpatient (dr./dietician/therapist each one time per week) or residential only...nothing in between. We are supposed to now have a 'doctor to doctor' call to determine my need for residential, so I haven't lost all hope yet. Sadly, this all happened on Friday as I was at the eating disorder center with my suitcase ready to check in. After this happened with the insurance company, I could still stay and just hope that the dr to dr call would result in acceptance, or go home and wait for the call to happen and THEN come back if accepted. I chose the latter as I just financially can't take the chance of staying through the weekend, only to find out that I've been turned down once this phone call has occurred. So I did turn around and go home - where I live by myself (i.e. no support), and have spent the three days since that time alone and using symptoms. My care-team and I are really hoping that the call occurs today - I'm not sure what I'll do if the outcome is not positive. I can't even allow myself to look that far ahead - I can't even fathom... :(