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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. Page  | 44