Appealing Denials for Mental Health
Many people have had the unhappy experience of being denied insurance coverage for mental health treatment they, their family, and doctor agree is medically necessary. Appealing denials for mental health can be complicated, frustrating, confusing, and difficult to navigate. Below are definitions of some of the most common terms used when health services are denied.
- Medical necessity criteria are standards used by health plans to decide whether treatments or health care supplies recommended by your mental health provider are reasonable, necessary and appropriate. If the health plan decides the treatment meets these standards then the requested care is considered medically necessary.
- Utilization review, also known as utilization management, is the process used by insurers to decide whether the requested mental health care is medically necessary, efficient and in line with accepted medical practice. In line with accepted medical practice means that mental health treatment or service is proven to be effective based on scientific evidence.
- Prior authorization, also known as pre-approval, preauthorization, prior approval or precertification, is a type of utilization review and is when you or your service provider must ask for approval before your health plan will agree to pay for a service, treatment plan or prescription drug.
- Step therapy is a type of prior authorization in which you must try a less expensive prescription drug or service before you can move to a more expensive prescription or service.
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A ‘denial of care’ is when a health plan does not pay for services or refuses to agree to treatment. All health plans are required to contact you in writing about their decision to deny care. They must give you the reason for the decision and you have the right to appeal that decision. Denials may also include reimbursement decisions contrary to your plan. Keep the following points in mind to increase the success of your appeal:
- When you speak to the representative of your health plan tell them you are appealing their decision and want to know how to do this.
- Maintain a written record of all your contacts when you are appealing. Always write down the full name of the person you speak to, their role, the content of your conversation and the time and date of the call.
- Follow all timelines and procedures for pursuing your appeal.
- Submit your appeal in writing.
- Exhaust all levels of appeal. Do not become discouraged and stop. It may be the last level of appeal, outside the company, that reverses the original decision.
The ability to make a successful clinical appeal when requested treatment services are denied by an insurer is an important skill for a psychiatrist to have in today’s environment. No one strategy will prove successful at all times and in all situations; often success will lie in a combination of approaches depending on the case in hand. Your insurance carrier must provide you information on how they made their decision to deny you coverage. Once obtained, you have the right to appeal that decision.
- Request and review a copy of the MCO’s appeals procedures and utilization review (UR) criteria before initiating any appeals.
- Ask for the case manager’s credentials. Denials of psychiatrists’ services should be made only by psychiatrists.
- Request written notification of the reasons for the denial and a description of the information required for approval. This will ensure that subsequent submissions “fit the bill.”
- Request names and addresses of the people who should receive applications for an appeal and find out the MCO’s deadline for appeals.
- Meet all UR and appeal deadlines. If you do not, the merits of your case may not matter. Certification denials due to “administrative noncompliance” are rarely overturned. If the case is denied on an administrative basis (i.e., a request for continued certification was not made within the specified time, precertification procedures were not followed, or there were benefit coverage exclusions), you’ll need to explain any extenuating circumstances in your appeal.
- If your appeal is denied, appeal again. Many companies offer three or four levels of appeal. It is advisable to exhaust all levels of appeal before initiating litigation, should you be forced to proceed that way.
- Be concise. Don’t send more information than necessary and be sure to get permission from your patient to release that information.
- Request peer review with a psychiatrist trained in the same subspecialty who has experience in the treatment requested.
- In an emergency situation, request an “expedited appeal” over the telephone with the consulting psychiatrist. Most MCOs have such services.
- If applicable, ask the patient to enlist the support of his or her Personnel/ Human Resources Department. MCOs are often more responsive to their paying clients’ complaints than to complaints from physicians.
- In cases that are slow to respond to standard treatments, ask the company to “flex benefits” by working with you to find a cost-effective, alternative treatment approach.
- If coverage is denied after appealing, some companies may allow you to request an external review of the case with or without some cost-sharing.
- In truly egregious cases, copy your appeal to the state insurance commissioner. Seeing such a “cc” may elicit a more rapid and favorable response.
- Contact any professional association you belong to and any consumer advocacy groups that may be helpful. A complaint lodged by several parties will be stronger.
Certain types of mental health treatment services get denied at higher rates than other health conditions. If you are denied the following supports and services and you think you are entitled to them under your health plan you may want to consider filing an appeal.
- Residential treatment for mental illness
- Intermediate levels of care, such as intensive outpatient treatment, psychological rehabilitation, partial hospitalization and assertive community treatment (ACT)
- Office-based diagnostic and treatment interventions, such as diagnostic assessments, standardized tests like the Patient Health Questionnaire 9 (PHQ-9), which measures depression, and other services like psychotherapy
It’s been estimated that some practices can lose thousands of dollars if a physician doesn’t stay on top of collecting outstanding balances and resubmitting denied claims within the time allowed. The importance of tracking claims denials and staying on top of resubmitting them cannot be overestimated. E2E Medical Billing Services can assist you in handling your denials. To know more about how we can increase your revenue by eliminating denials you can call us at 888-552-1290 or write to us at info@e2eMedicalBililng.com