How to Advocate for Insurance You Deserve
Educating your insurer
Remember that your request for treatment is reasonable and that you have been paying for insurance so you and your family would be covered in case of a life-threatening illness. Keep in mind that insurance companies are not the enemy, but they don’t always realize how life-threatening eating disorders are.
Your job is to educate the insurance company so it understands the necessity of treatment. It is always easier to get your insurance company to work with you if you approach their representatives in a non-threatening manner. Try to set your emotions aside and always be civil, polite, and determined (not aggressive). Our Insurance Verification Tool can help you communicate with the insurance company.
Many people write two letters to their insurance company. The first one is full of emotion and states what you really think and feel. You “let it all out” in this letter, then tear it up and begin the second letter. This letter is polite and respectful, while still conveying your determination and your unwillingness to give up until you get the care that you or your loved one needs.
Know your policy
If you’re running into resistance from your insurer, you’ll need to read your insurance policy and determine what mental health benefits you have. If you have difficulty understanding the document, call the Customer Service number on the back of your insurance card and ask for explanations. Don’t hang up until all of your questions are answered, you understand the answers, and you know the practical consequences of the insurer’s policies and procedures. You must have accurate information as you move forward.
Ask for a case manager if you’re not getting the information you need.
Since treatment at The Emily Program is comprehensive and personalized, be sure you understand which parts of treatment are covered under the medical benefits section of your plan and which are covered under the mental and/or behavioral health section. (The Insurance Verification Tool can help you keep track.)
You also need to understand the insurance company’s “rules.” Call your insurance company and ask them to explain such things as the appeals process, what criteria they use to determine medically necessary treatment, and who makes those decisions.
Know the law
When an insurer denies coverage, they may not be clear about the true conditions, standards, and criteria for their decision. That puts you at an unfair disadvantage during any appeals process. Request a copy of the written criteria and also the names and positions of the people making the decisions. Get contact information for the President/CEO of the company and send copies of all letters to them.
Remember to carefully document every phone call, including the name of the person you spoke to, date and time, and what was said or decided. Follow your insurer’s process and be very careful when you submit forms. We find that long delays are often caused by insignificant omissions or mistakes such as leaving out a requested number.
Request that the level of care decision be based on the widely-accepted American Psychological Association guidelines for treating eating disorders. If the request is denied or your insurance company states they use a different set of guidelines, insist that they take full responsibility for the consequences, noting that they are diverging from the guidelines established by qualified experts in the field.
There will be times when you can solve the problem quickly and relatively easily. If you receive a letter denying the requested treatment, call the company. Typically, the person answering the phone cannot reverse the decision, so ask to speak directly to the Medical Director. Ask the Medical Director for a detailed explanation of why the request was denied and what criteria was used to make this decision.
Try to “join” with them by stating that you believe an error was made and that it needs to be reversed. Have your documents at your side so you can explain clearly and effectively why you are right. Again, it is very important that you document everything discussed.
If the simple attempt does not work, you will need to file an appeal. Be sure you understand what the company’s appeal process is and follow it completely. Once you have the information you need from the insurance company, start putting together a packet to send to the review committee and the president of the insurance company. Write a letter that is brief, clear and states your expectations and goals concisely and in understandable terms. Include a brief recap of your story and ask for a response within a defined time period.
Your appeals packet should also include documentation, evidence and facts. Insurance companies may deny or limit coverage after mere “paper reviews,” contradicting the judgment and recommendations of the professionals who have examined and treated you or your family member. Ask your treatment team for documentation supporting your request and the rationale for the recommended treatment. It may also be helpful to include research and other scientific evidence.
To find appropriate information, ask your doctor, psychologist or other professional or look at the website of the Academy for Eating Disorders, a professional organization that publishes the latest research findings.
Send all of this information to the insurance company. Be sure to copy it to the president of the company; your state’s Attorney General and Insurance Commissioner; your local state representatives, U.S. Senators, and Members of Congress; advocacy organizations; your attorney and anyone else you think might be interested. If you have an insurance agent or a human relations representative at your company, copy the material to him or her and ask for assistance.
Keep speaking up
Too many people around the country must battle with their insurers for months and years (sometimes being forced to file lawsuits) to get the coverage they paid for and deserve.
That’s why our last piece of advice is so important: DON’T GIVE UP. Most insurance companies count on people accepting the denial and not following through with the appeals process. We recently heard that when people follow the entire process, they win in 75% of the cases.
We are sorry that you are in this position and we wish there were easier answers, but we trust that over time and with thousands of people like us fighting, we will change the system. If you are interested in joining the national advocacy movement to end discrimination against people with eating disorders, go to Eating Disorders Coalition for Research, Policy & Action website. EDC works in Washington on legislation that will have a nationwide impact.
In Minnesota, you can join the advocacy efforts of The Emily Program Foundation. Remember, you are not alone in this fight!