NEDA TOOLKIT for Parents
Understanding Insurance Issues for
Eating Disorders Treatment
One of the most common questions received at the
National Eating Disorders Association is about issues
with insurance. Whether for outpatient therapy,
inpatient hospitalization, or anything in between,
understanding your policy’s benefits and obtaining
authorization for the appropriate level of care can be
confusing and frustrating. This section of the toolkit
will provide an introduction to some of the basic steps
involved in utilizing your insurance benefits to help pay
for a loved one’s treatment.
Note: If your loved one is under 18, a parent/guardian
can legally act on their behalf without prior approval.
If your loved one is over 18, they will need to sign a
document letting you work with the insurance company
on their behalf, even if you are the parent/guardian
and the policy is in your name. A customer care
representative at the insurance company should be able
to tell you or your loved one what documents need to
be submitted to allow another person to act on his/her
behalf. Proper treatment of an eating disorder must address
both the psychological and physical aspects of the
disorder. Many insurance companies have mental
health benefits (also known as behavioral health
benefits) under a separate umbrella from their
physical health benefits. The recent passage of mental
health parity means that, legally, mental health must
be covered on par with physical health. However,
the separation can still exist, and behavioral health
coverage may even be contracted out to a separate
company under the supervision of the insurer. All of
this combines to create a confusing patchwork array of
coverage and rules that can make obtaining proper care
for your loved one difficult.
For example, when a service is provided by a
doctor or facility, a billing code is needed to obtain
reimbursement for services. Certain rules and
regulations govern how services must be coded and
who can perform those services. Different types of
facilities and different healthcare professionals must
use codes that apply to that type of facility and health
professional. Also, if codes don’t exist for certain
services delivered in a particular setting, then facilities
and health professionals have no way to bill for their
services. Codes used for billing purposes are set up
by various entities, such as the American Medical
Association, U.S. Medicare program, and the World
Health Organization’s International Classification
of Diseases. Thus, even a patient with good health
insurance may face barriers to care simply because of
the way our healthcare system is set up.
Given that appropriate well-integrated treatment for
eating disorders can easily cost more than $30,000
dollars per month, even with insurance, an insured
individual is usually responsible for some portion of
those costs.
The first-line of decision making about health plan
benefits is typically made by a utilization review
manager or case manager. These managers review
the requests for benefits submitted by a healthcare
provider and determine whether the patient is entitled
to benefits under the patient’s contract. These
decision makers may have no particular expertise in
the complex, interrelated medical/mental healthcare
needs for an eating disorder. Claims can be rejected
outright or approved for only part of the recommended
treatment plan. Advance, adequate preparation on
the part of the patient or the patient’s support people
is the best way to maximize benefits. Prepare to be
persistent, assertive, and rational in explaining the
situation and care needs. Early preparation can avert
future coverage problems and situations that leave the
patient holding the lion’s share of bills.
The rest of this section will contain tips to help you
obtain the insurance benefits your loved one needs and
deserves so that they have the best chance possible to
recover from an eating disorder.
Educate yourself
Read the other information in the Parent Toolkit to
learn about eating disorders, treatment, current clinical
practice guidelines, and how you can best advocate
for and support the family member who has an eating
disorder. Refer to the latest evidence-based clinical
practice guidelines in this toolkit and have them in
hand when speaking to your health plan about benefits.
Be prepared to ask your health plan for the evidence-
based information they use to create their coverage
policy for eating disorders.
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