NEDA TOOLKIT for Parents
Landmark lawsuits brought by families of patients
with bulimia nervosa and/or anorexia in two states—
Wisconsin in 1991, and Minnesota in 2001—were
watershed events that set legal precedents about
what insurers should cover for eating disorders. These
lawsuits also raised public awareness of the problems
faced by people seeking coverage for treatment of
eating disorders. Nonetheless, the system today has a
long way to go to improve access to care and
adequate reimbursement for care for a sufficient
period for a patient with an eating disorder.
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, inter-related 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 patients’
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.
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