National Eating Disorders Association

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8MosIn
Insurance Pitfalls for Inpatient Care

My daughter was recently discharged from an inpatient program and everything went very well. So far so good, one day at a time, but right now she is a totally different person than she was two months ago. I'm proud of her and happy for her.

I shared part of her story in a previous post in a different thread.

Here are a few pointers I wanted to share for parents who are considering sending their child (under the age of 18 or still on their medical insurance) to an inpatient program/clinic (this is pretty long, my apologies):

***Contact your insurance before you make any plans or admit your child to a facility. Explain what the situation is and ask about coverage. Ask if your insurance company makes the determination of coverage or if it's a third party. Check your policy if possible and read the fine print.

My daughter's entire stay was denied as my insurance company employs a third party to make determinations of coverage regarding behavioral health. The denial happened on her third day as inpatient...she was already admitted. This third party requested a peer-to-peer consult with the doctor at the facility my daughter was admitted to. The third party decided intensive outpatient treatment closer to home was more appropriate (she went out-of-state for inpatient treatment, the clinic was about 100 miles from our home). We had tried that, it didn't work, things had gone too far in a very short time and she felt hopeless, even entertaining the idea of suicide.

The third party NEVER contacted her therapist (who she'd been seeing since she started calorie restricting), nor did they contact the IOP she was receiving treatment from.

***While you're still doing research on inpatient programs, request a clinical summary from anyone your child was treated by for their ED. Therapist, IOP, medical doctor...anything and everything that will provide a broader picture as to why inpatient treatment is necessary. Provide this information to the inpatient facility. Offer it to your insurance company. Give it to anyone involved with the coverage decision-making process. They won't search it out on their own, you'll need to provide it.

***Medical necessity or a harm to themselves or others...that's a big one.

My daughter began as anorexic. She was calorie restricting. After months of this, she morphed into bulimia and her binge/purge cycle spun out of control in just two short months. This resulted in her gaining back the weight she lost.

Because (when she became inpatient) her weight was considered appropriate for her height and her labs came back still within normal ranges, the third party considered inpatient as not being a medical necessity. And the third party did not contact her therapist or IOP, so they were not aware of her mental state, aside from the inpatient facility making them aware based on her clinical assessment at the time of admission. Had she returned home and not experienced inpatient treatment, I may very well have lost her to suicide if not the ED.

***When contacting an inpatient facility ask what their pre-authorization process looks like.

Tell them what insurance you have and ask for a pre-authorization to be submitted to your insurance company prior to admission. I was told by the facility I chose that my insurance company only accepts pre-authorizations upon admission, not before. THIS IS IMPORTANT...GET THAT PRE-AUTHORIZATION PRIOR TO ADMISSION. Nothing is worse than getting a call 48 hours after dropping her/him off that she/he's not covered and she/he will need to be picked up.

***Inpatient treatment for anorexia is covered on a fairly regular basis, bulimia is not. Unless it's a 'medical necessity'.

***Do a lot of research on facilities, contact your insurance company, and above all (and this is difficult) make decisions with a clear head, not rooted in emotions or the heat of the moment. I'm a single mom and went through all of this alone as the sole responsible adult. Doing your homework ahead of time goes a long way. And most of us don't know this until we're knee-deep in the situation.

***I was able to get a personal loan to keep my daughter in the inpatient program. That doesn't mean it's the end. I'm currently in the midst of an internal appeal process. If that doesn't yield results, then I can move on to the external appeal process. Know your rights as the insurance subscriber. Talk to your employer's Human Resources department if need be. Don't let it go...keep fighting. It's when we don't hold insurance companies and their third parties accountable that they continue to get away with denying patients coverage who are in desperate need of inpatient treatment.

Many apologies for this long, long post. There's more I could share, but these are the most important points.

I'm hoping it helps parents who (like myself) have no prior knowledge about any of this and the pitfalls you can encounter without doing research and due diligence with insurance companies and inpatient facilities.

I wish the absolute best to all families and individuals struggling with ED. Take care and take things one day at a time.