January Pathway on Insurance a Big Success

On Wednesday, January 22, NCPSG hosted Joe Feldman, President of Cover My Mental Health, for a discussion on overcoming insurance obstacles to behavioral health care. After describing a number of specific actions that family members or loved ones can take, Joe answered questions from parents.

Joe is a mental health advocate who is one of the few who can claim to take a health insurance dispute all the way to a state’s highest court and win. While advocating for year, he founded his nonprofit Cover My Mental Health a year ago, and is continuously improving both his recommendations and his website. The last thing he would recommend is to appeal and dispute.

Rather, Joe’s approach is to be proactive, so that the individual is prepared when questions or obstacles with the insurer arise. He talked about 3 broad concepts during his presention: 1) Steps to get started; 2) Responding to obstacles; and 3) Additional resources that could be utilized to help overcome issues, including state and federal government contacts, as well as employer support. Joe’s view is that appeals, external reviews, single case agreements and lawsuits should only be used as a last resort. He doesn’t believe in a “fighting” or aggressive approach.

Among steps to get started, Joe recommends a “Show Me Your Homework” worksheet (template on website) that documents the different providers contacted that are qualified, nearby, in-network and available. That way, if no providers are available locally, then it’s reasonable to assume that the insurer will pay for an out-of-network provider as if in-network.

Joe also believes that medical necessity letters are extremely valuable, which detail why a clinician believes a higher level of care is necessary. What you don’t want to happen, is for the insurance company to make that decision. These letters should be in place whenever a denial is anticipated or likely. A template for a letter that the clinician would write is available on the website.

With regards to claims being paid, we as consumers can reasonably expect that the care is covered. Joe believes there are many steps that can be taken before having to go to appeal.

One step: send the health insurer a letter requesting the individual’s entire file. This will include clinical notes from external reviewers as well as the policy document itself. Second step before appeal: Call insurer and say “I want to file a formal complaint”, for a “quality of care failure”. Insurers have to respond to this, and they don’t like it because they have to report complaints to their state regulator. Again, there is a template on the website.

Finally, Joe recommends utilizing the resources at the state and federal level, including: 1) State insurance regulators; 2) Federal regulator with the Dept of Labor called the Employee Benefit Security Administration; and 3) Constituent Services of legislators. The website provides links. [NOTE: In CT, there also is an Office of the Healthcare Advocate, which may be a resource as well. ]

Conclusion: Joe’s nonprofit and website are unique resources to help individuals with insurance obstacles to getting quality care for mental health and substance use conditions. Please check it out, by going here first: covermymentalhealth.org.

Click here for the presentation slide deck and click here for the video replay.