Multiple laws, including the Affordable Care Act and the Mental Health Parity and Addiction Equity Act, have been passed to ensure that insurance companies provide coverage for mental health conditions. These laws require equal coverage for addiction and physical ailments. Your plan should use the same co-pay and deductible rates for all care, whether it is at the cardiologist’s office or the psychiatrist’s office.
However, insurance companies continue to deny or limit mental health coverage for patients. Lately, these wrongful denials are leading to large court cases and showdowns between patients and payors that may give you more access to coverage in the future.
How Courts Are Siding With Patients
For more than a decade, the California insurance commissioner’s office has led a case against United Healthcare Group (UHC) for wrongfully denying insurance coverage. The case has included more than 900,000 violations, the largest number ever found in the state’s history.
In January, the California State Supreme Court ruled in favor of patients, ordering UHC to pay $91 million in fines. The court’s ruling will help the state of California better police insurers and protect patients.
UHC is not the only insurer to be accused of wrongfully denying claims in California. The insurance commissioner has also launched an investigation into Aetna based on a lawsuit brought by a college student. In deposition for that lawsuit, Aetna’s former medical director admitted that physicians were not reviewing medical records to determine medical necessity. They were only provided “pertinent information” from nurses. This process may have led many patients to be denied coverage for treatments they desperately needed.
Thanks to the UHC decision, the commissioner may have a stronger case against Aetna. While the state’s decision doesn’t affect insurers in other states, it may help patients in other states support their cases. It upholds the legal right of states to hold insurers accountable. And dozens of these cases are underway across the country.
One such case, a class action lawsuit against United Behavioral Health, focuses on its violation of mental health parity laws in Illinois, Connecticut, Rhode Island, and Texas. In a scathing decision against the company, the federal judge said the company was deceptive and put its bottom line ahead of the patient’s health. The case uncovered ways that the company crafted its own guidelines so it could find ways to deny coverage later.
Because this ruling was so large and was a federal ruling, it may have a huge impact on patients across the country. It will set a precedent for many other cases and, hopefully, lead to changes in how insurance companies conduct business.
The Cost of Denied Insurance Coverage
It is important to remember that denied coverage isn’t just a matter of money; it can mean the lives of patients who desperately need help. Denied coverage can keep patients from getting the care they need, increasing the rates of suicide or overdoses. Patients who receive lower level care than they need are still at great risk of poor outcomes.
Judges are taking the human cost of denied coverage into account, which explains the strength of their rulings and the steep financial punishments. Though the fight for parity is not over, each ruling makes it more likely that patients will be able to get the lifesaving care they need.
How to Appeal Denied Coverage
If you or a loved one has been denied coverage of mental health services, you can fight the decision. First, you should file an appeal with your insurer directly. Insurers must tell you why they denied your claim.
Sometimes claims are denied for simple reasons, like a misspelling or typo in your paperwork. Review your claim carefully to ensure that there are no mistakes. If you find a mistake, you can correct it and your appeal is likely to be approved.
However, if your claim is correct, you may need to collect evidence that the treatment is medically necessary. Your doctor’s office can help you collect referrals, prescriptions, and any other relevant information. Your doctor may be able to help you prove necessity.
It’s vital that you follow your insurer’s claims process exactly. This may include writing a letter to your insurer appealing the claim. Always be sure the letter includes your claim number and the ID number off of your insurance card.
You may have to call your insurer multiple times to keep up with the claim. Each time you do, get a call reference number and the name of the person you are speaking with. Take notes to bolster your case and follow up regularly.
Unfortunately, you can do all the work above and still end up with a denied claim. You still have the right to an external review of the claim through your state. File a claim with your state’s department of insurance to have a third party review the case and hopefully rule in your favor.
At Harmony Place, we will work with you to determine if your care is covered and help you create a financial plan if your insurance does not cover addiction treatment here. We can help you find ways to appeal denied claims and ensure you have coverage before you start treatment. Start your insurance verification process online.