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Support forum for parents and caregivers of anorexia, bulimia and other eating disorder patients

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Around the Dinner Table - Parents of ED Children > Forums > 2009 Posts > we won our insurance appeal
 
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ruralmomUSA
Mentor
Registered: Aug 21, 2007
Posts: 443

    March 19, 2009 at 10:21 AMReply with quote#1

Wanted to let everyone know that we won our insurance appeal for treatment provided at UCSD for our family.  Originally, our insurance denied our claim because it was deemed experimental.  We modified a letter on the NEDA site and used all of the wonderful research accumulated on the FEAST site to back up our request.  I just found out today, we won!  It went all the way to the top of our insurance company.  If anyone is in the same boat as us with their insurance company, I'd be happy to share a copy of our letter. 

IrishUp
Mentor
Registered: Sept 05, 2007
Posts: 307

    March 19, 2009 at 10:24 AMReply with quote#2
WOOOT!
Great to hear that all your hard work and persistence have been rewarded.
A win for you may also help other families make their cases. And perhaps one day people will just get the healthcare they need!

Congratulations!

LauraCollinsUS
Moderator
Registered: July 31, 2007
Posts: 4,036

    March 19, 2009 at 10:56 AMReply with quote#3
This is HUGE! This is wonderful!

You have created a precedent, an inspiration, and blazed a trail for others. I'm so excited. It also strikes me that this will be helpful for other patients at UCSD's state of the art program!!

I'm going to link this on our insurance page at F.E.A.S.T.

Thank you SO much for sharing this, and congratulations to you personally.  WAY TO FIGHT FOR YOUR KID and YOUR FAMILY!!
lydia
Moderator
Registered: Aug 04, 2007
Posts: 2,769

    March 19, 2009 at 11:05 AMReply with quote#4
ruralmom,

YOU ROCK GIRLFRIEND!!! Thanks so much for sharing this news, every battle won gives so much hope to other families. It's hard enough to battle eds, battling insurance companies for coverage only adds to this ordeal.

WOW and WOW again!
pennysgirlUSA
Mentor
Registered: Nov 06, 2008
Posts: 1,783

    March 19, 2009 at 11:11 AMReply with quote#5
Oh you have inspired me to spend some time writing my second appeal letter to get them to cover our T. It will be a big project for me, though b/c our blue care network has also turned down an insulin pump for my son and a different ADD medication for my little d... so if I write one letter, I have to write three. I am going to look up info now, and please, I would love to see your letter!
JC
Registered: Jan 09, 2009
Posts: 219

    March 19, 2009 at 11:51 AMReply with quote#6

That's fantastic.  Your persistence paid off!

I agree with the posts above, it paves the way for others. 
LV
Mentor
Registered: Oct 19, 2008
Posts: 954

    March 19, 2009 at 02:34 PMReply with quote#7
Yay!
BridgetAUS
Moderator
Registered: July 31, 2007
Posts: 1,067

    March 19, 2009 at 03:53 PMReply with quote#8
You will have helped so many here. Fantastic.
Bridget

ms
Mentor
Registered: Aug 09, 2007
Posts: 675

    March 19, 2009 at 05:01 PMReply with quote#9
Way to go Ruralmom! Once piece at a time we will fight for what our children need and deserve in the treatment of eds. 
I also used a template from the "Anna Westin" Website for insurance denials as well as attachments from the American Psychiatric Assoc. in addition to my Dr. letters (these alone were not good enough in the beginning) I then went to my State board of Insurance and talked directly to them on the phone. I gave them ALL the info as well as names, dates ect. of every correspondence I had had with Ins. co. (FEAST was just getting organized) It took allot of hard work and TIME, but it worked. In the end, through our state dept. of insurance, we found out that our original policy was incorrectly quoted in the number of covered days (since ins. must abide with state mandated coverage for a large group employer) I should not have had to go through any of it!! Actually, we were contacted about pursing a legal case as this was a violation of the ERISA law. We did not pursue it, All I ever wanted was for her to receive the care she needed and deserved. She left the php at a "medically stable weight"  Even after we found out she did have more "days of coverage" we continued to refeed at home. We did take them up on the unlimited amount of outpt therapy, that is once she was at a healthy weight for some time. I think dealing with all the ins. nightmares broke me almost as much mentally as watching my d held hostage by ed.  I was physically and mentally exhausted after dealing with them!  I spent hours each day making phone calls and emailing letters, then she would come home and cry and rage until she went to bed.  Life was not good. 
In hindsight, I think it happened this way for a reason. Once she was out of php, we had the knowledge and strength to continue to refeed on our own. (this website and FEAST getting going) We may have saved someone else from going through the same thing with the insurance. They were legally obligated to send an apology letter to everyone within our large group employer explaining the policy was incorrectly written as far as days of coverage for serious mental illness in children (which exposed more people to what we were dealing with and how we were handling it) It showed me that I had strength and determination I never thought I had. I truly don't think I could have done all that and been refeeding at the same time. 
Can you imagine someday looking at your insurance policy and seeing eds even addressed (instead of making 20 calls just to find out if it is being handled as a medical or mental illness) And seeing fbt as a choice of treatment? 
ruralmom-I know not all ins. endings go the way ours have, but fighting for treatment our kids deserve will hopefully pave the way for others in the same boat. Way to go !!!
bonusmom
Registered: Dec 22, 2008
Posts: 480

    March 19, 2009 at 10:09 PMReply with quote#10
YEAAHHH! A great precedent for advocacy that is going to be much needed for many in the future.

We just got our TRICARE claim, and it says it all costs...$53,000. Right now, I do not think that is what we will be billed for, but it is astounding.

You are an amazing trooper dealing w/ all the bureaucracy and figuring it out. KUDOS without end.

ruralmomUSA
Mentor
Registered: Aug 21, 2007
Posts: 443

    March 20, 2009 at 01:19 PMReply with quote#11

You're right MS. We shouldn't have to fight for coverage of appropriate treatment for our kids. It is exhausting and very unfair to deal with such a devastating condition and then have to work your way through the bureaucracy too.  You start to wonder who's sicker- your child or the system?

ruralmomUSA
Mentor
Registered: Aug 21, 2007
Posts: 443

    March 20, 2009 at 01:21 PMReply with quote#12
Pennysgirl,

If you want to e-mail me privately, I'll send the letter we used to you.
Christopher
Mentor
Registered: Oct 18, 2007
Posts: 182

    March 20, 2009 at 04:13 PMReply with quote#13

Dear ruralmom,
This is huge!  It is about time that insurance companies paid attention to the evidence that family-based nutritional rehabilitation is not experimental but is actually the treatment model grounded most solidly in scientific evidence. For example, as shown on the F.E.A.S.T. website, a scientific review funded by the National Institute of Mental Health last year concluded: "At this time, the evidence base is strongest for the Maudsley model of family therapy for anorexia nervosa."  Keel and Haedt, "Evidence--Based Psychosocial Treatments for Eating Problems and Eating Disorders," Journal of Clinical Child & Adolescent Psychology, 37(1), 39-61 (2008).  In addition, an article published in the New England Journal of Medicine on January 29, 2009 concludes that for younger patients suffering from anorexia, "the Maudsley Method is generally recommended." Attia and Walsh, "Behavioral Management for Anorexia Nervosa," NEJM, Vol. 360:500-506.
Given that there's more evidence to support Maudsley than any other model of treatment, it is beyond debate that insurers should cover the costs of FBT.
As it is now, insurers are paying for lots of stuff (ropes courses, equine therapy, yoga, etc.) that may be well intentioned but have never been shown to be effective in the treatment of anorexia, in any systematic scientifically valid studies.

Maybe you could white out the names on the correspondence between you and your insurer (to protect privacy) and send the letters to Laura so she could post them on the F.E.A.S.T. site?  That way, others could use your letters as a model of how to get good results.

Congratulations!


JC
Registered: Jan 09, 2009
Posts: 219

    March 20, 2009 at 05:46 PMReply with quote#14

Ruralmom:

Christopher suggests a great idea, i.e. posting the letter on the FEAST website so others can use it as a model, if you would be willing to.  I'm sure many of us would find it beneficial. 

Again, great job!


 
ruralmomUSA
Mentor
Registered: Aug 21, 2007
Posts: 443

    March 21, 2009 at 03:24 PMReply with quote#15

I'm more than happy to post the "sample" letter on the FEAST website.  As Christopher suggests, we included references to current research (from the FEAST website).  What a lifesaver!  We  had our Dr. write a letter supporting her referral and UCSD released clinical notes.  We also cc'd everything to our state insurance commissioner, who I later found out didn't have jurisdiction over our insurance company.  I do think it let our company know we weren't afraid to make our situation known, if we had to.  I'll e-mail the letter to Laura. Thanks for the suggestion.

SallyA
Registered: Sept 07, 2009
Posts: 3

    Sept 07, 2009 at 04:17 PMReply with quote#16

Has anyone had any experience with United Behavioral Health (UBH) mental health insurance with getting approval for residential treatment pre-approval? We have just had my 22 yr old daughter denied in early stages of request. Appreciate any advice that is out there. This is all new to me/us to get her help. Thanks much!!

Mamame
Moderator
Registered: Oct 30, 2008
Posts: 3,168

    Sept 07, 2009 at 04:49 PMReply with quote#17
Hi Sally, so sorry you had to find us but I know you will be glad you did.
I haven't had any experience with UBH but I can point you to some of the guidelines they adhere to and thus give you some more info with which to appeal.

http://www.psychiatryonline.com/popup.aspx?aID=139471
https://www.ubhonline.com/html/guidelines/preferredPracticeGuidelines
According to there clinical pages they follow these guidelines.

Many times you need to gather the evidence from previous providers or present  Dr's  and submit it. Many have had success by having the recommending Dr submit a letter explaining their reasoning why the patient needs a particular standard of care. Most Dr's are only too happy to do this as they want the best for their patients.

Also see these pages in FEAST if you haven't already:
http://www.feast-ed.org/specialistdirectory.html
Levels of care
Insurance and money issues
Navigating and Understanding Insurance
Legally adult children

Please ask if there is anything else we can help with, we all know how difficult and exhausting helping a loved one with ED is.

M

SallyA
Registered: Sept 07, 2009
Posts: 3

    Sept 07, 2009 at 05:02 PMReply with quote#18

Thank you so very much. Your quick response heartens my soul to win this battle. Will follow your advice.

Mamame
Moderator
Registered: Oct 30, 2008
Posts: 3,168

    Sept 07, 2009 at 05:08 PMReply with quote#19
You are welcome.
Do you have paperwork signed by your daughter so that you can gather her records and deal with her care while she is unable to?
These would be HIPPA forms and Health Care Proxy's or alike.
See this site for details:
http://www.treatmentadvocacycenter.org/LegalResources/statechart.htm
Often these can be downloaded and you can sign them at home in front of a witness.
SallyA
Registered: Sept 07, 2009
Posts: 3

    Sept 07, 2009 at 05:30 PMReply with quote#20

great idea. But, I can't seem to find a form or template such as you mention.

Mamame
Moderator
Registered: Oct 30, 2008
Posts: 3,168

    Sept 07, 2009 at 05:42 PMReply with quote#21
 HIPPA form:
http://www.aafp.org/fpm/20030200/29theh.html#box_d

Depending on your state there may also be a Power or Attorney form or Health Care Proxy form that would aid you in seeking her care.
http://en.wikipedia.org/wiki/Health_care_proxy
http://www.nupplegal.com/health-care-power-attorney.html
http://en.wikipedia.org/wiki/Power_of_attorney
http://en.wikipedia.org/wiki/Advance_health_care_directive

If you page all the way down there are example links.

Some Dr's offices have the forms in their online patient forms.

pamom
mentor
Registered: March 05, 2009
Posts: 110

    Sept 07, 2009 at 07:16 PMReply with quote#22
Wow!   

I am inspired by your tenacity and others will surely benefit from the precedent you have set.   This makes SO much sense - our children recover more quickly and the insurance co. spends less money.  Win-Win!

Thank you for paving the way and for not giving up!
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This forum is sponsored by F.E.A.S.T., an organization of parents serving parents and caregivers of patients of all ages with anorexia, bulimia, and other eating disorders. The moderator team is led by Laura Collins, a parent and author who serves as FEAST's director. Posts by longtime members of the forum experienced in seeing a patient through to recovery are designated "Mentors." If you wish to nominate a mentor, please contact us. Information and advice given on this forum does not necessarily represent the policy or opinion of F.E.A.S.T. or its volunteers.
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