F.E.A.S.T's Around The Dinner Table forum

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MBR
We had a while when Kaiser denied our request for residential treatment and a out of network facility they only want my daughter to go to their facility even though it failed two times before and didn’t give her adaptive skills on how to function outside of The facility Does anyone have any experience with this or suggestions on how to handle this because her health is very fragile and she is high-risk.Would appreciate any suggestions. Thank you
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sk8r31
Do you have an insurance case manager?  Have you considered approaching your healthcare insurer to have a 'single-case' agreement approved?  Having a case manager (you may have to ask, though in our case it was offered) means that you deal with ONE person, instead of having to give all your info multiple times to multiple people.  And a single-case agreement is one that your insurer will approve on a 'single-case' basis if you can document how whatever treatment you are wanting to have covered will benefit your kid, AND save the insurer money.  We were able to get the entire amount of our UCSD treatment covered, instead of the 60% originally offered by the insurance company.
It is challenging to deal with insurers and out of network providers and facilities.  Remaining calm, or even having a trusted family member or friend dialing the number and helping you prepare what to say can help.  At the beginning of our journey, I couldn't talk on the phone to the insurance company without crying...I was so emotionally devastated.
Sending warm support,
sk8r31
It is good to not only hope to be successful, but to expect it and accept it--Maya Angelou
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MBR
 Thank you for your very thorough and informative information. It is very helpful. I am not sure if my daughter is assigned a case manager it was my understanding she should’ve had one when she was hospitalized but we weren’t given that information. Do I contact the hospital to get that name or is that a different case manager that you’re speaking of? Is it a case manager for the insurance or one from Kaiser  it  self? Do you need to request to have one or is one assigned to your case automatically? I am very encouraged that you had a good outcome with your insurance and were able to get the care you needed for your loved one. Thank you for sharing your heart.  It has been an emotional roller coaster for me and it is so hard to remain calm and it’s a good idea if maybe I could get a friend to help me so I’m not so emotional. I know it’s not personal it’s just red tape. I would think the insurance would want to approve if it’s the insurance that’s the problem because they won’t want to pay for multiple relapses I would think they would want to get to the root of the problem so she can learn the skills how to function and adapt outside of the residential care. Thank you for taking the time to give me feedback.
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sk8r31
We were asked by the insurance company if we wanted a case manager, so it wasn't at the hospital or treatment center.  I had called the insurance company numerous times and was finally offered a case manager, so we wouldn't have to keep explaining the situation many times to different people.  It really was a help.  You may have to ask your insurer for this.  Again, I think it is helpful to lay out what treatment and where you are proposing to go, and why.  If you can cite any info or references as to the evidence-based nature of the place/treatment you are requesting, plus are able to show how it can save the company money, it will aid your request.  For us, the office staff/insurance specialist at UCSD was very helpful in getting our request for full coverage granted.  So depending on where you are planning to go, or what treatment you are seeking, there may be folks available to help you get as much coverage as possible.
Warmly,
sk8r31
It is good to not only hope to be successful, but to expect it and accept it--Maya Angelou
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mommiful

We looked into single case agreements a few times, after having tried the only local option multiple times. We had varying experiences. At one point I was told that the provider you want to use needs to contact the insurer directly. They did a phone assessment with both me and my daughter and then contacted insurance and reached an agreement. The single case agreement was negotiated between the provider and the insurer, and we did not have anything to do with it. Another time, however, we were told that we had to initiate the process, and then promptly denied. (The insurer agreed that the RTC where our daughter was receiving treatment was not providing adequate care, but the said we could not have a single case agreement because we had the option of going to another in-network within a 500 mile radius. If there had been no other options within 500 miles, they said we would have qualified.)

A good outpatient provider might be able to advise you about good programs that might be able to help you get a single case agreement. Ours gave us the tip that the single-case agreement depends on both sides (RTC and insurer) agreeing, and some RTCs tend to be more willing to negotiate than others. Some programs take pride in being able to work this out. Nonprofits and programs affiliated with hospitals may be a better bet. It certainly doesn't hurt to ask any program that you're considering whether they would be able to help you get a single case agreement.

RTCs may also be more willing to negotiate at times when they have open beds. Unfortunately, residential treatment tends to get crowded in early summer, since people often push to complete the school year before resorting to residential.

RTCs with locations in multiple states may have different relationships with insurance for different locations. If one of the other locations is in network for the insurer (or an affiliate of that insurer in a different state), that can make it easier to get a single case agreement at the location that is out of network. That worked for us at one point, and it was handled entirely between the provider and the insurer.

RTCs may also offer to charge you at the in-network rate without having a single case agreement. In that case, you would probably still end up paying significantly more than you would for an in network program, just not quite as much more. 

When we were in the market for residential treatment, we did our research on RTCs first, then worked with the ones we liked best to try to get the finances to work. I used asks along the lines of "We can't afford the cost of out-of-network treatment, but your program sounds like what our daughter needs. Is there anything you can do to help make this more affordable." Some places just suggest a payment plan or loan; others bring up single case agreements and fee reductions.


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ValentinaGermania
I would also recommend to phone one of the highly recommended clinics like UCSF or UCSD or Kartini and ask the staff there how to get help from your insurance.
Keep feeding. There is light at the end of the tunnel.
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MBR
Thank you for your suggestion.Trying to get Kaiser to agree to a out of network residential care we found but they denied our request and only want us to go to there facility even though it failed two times before.I’m not sure if it’s a insurance issue or something else.It is unclear why.And I am worried for my daughter to be without treatment and she is getting worse.Please let me know what you think.Thank you
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MBR
sk8r31 wrote:
We were asked by the insurance company if we wanted a case manager, so it wasn't at the hospital or treatment center.  I had called the insurance company numerous times and was finally offered a case manager, so we wouldn't have to keep explaining the situation many times to different people.  It really was a help.  You may have to ask your insurer for this.  Again, I think it is helpful to lay out what treatment and where you are proposing to go, and why.  If you can cite any info or references as to the evidence-based nature of the place/treatment you are requesting, plus are able to show how it can save the company money, it will aid your request.  For us, the office staff/insurance specialist at UCSD was very helpful in getting our request for full coverage granted.  So depending on where you are planning to go, or what treatment you are seeking, there may be folks available to help you get as much coverage as possible.
Warmly,
sk8r31
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MBR
I really appreciate your feedback.It is so helpful.I had a question how do you get information for evidence-based nature of the place/treatment?Does that mean success rate?Also  I am unclear if the problem is insurance or if it is something else that is blocking Kaiser from referring an outside program? Not sure of their protocols and policy on how they handle these requests. Somehow it’s been done before since the place we wanted to go to said they have excepted Kaiser patients in the past and the way they suggested To get the ball rolling didn’t work and it was denied? I am very worried because my dad is getting successively worse and has brain fog and memory issues and this is really hard on her body to be going through this for so many years and I worry about long-term damage. I’m trying to be patient to get her into placement but it is very scary. Any feedback would be appreciated. Thank you for taking the time to read this.I am very grateful
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ValentinaGermania
I do not know how it is there but here it maybe would help to get an o.k. from insurance when you contact press or politicians. I got my insurance to pay for FBT that way although they refused first.
Keep feeding. There is light at the end of the tunnel.
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debra18
FEAST has a chat button where you can speak to someone with your questions. They might be more knowledgeable about how to help
 
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sk8r31
I did a search on the Around the Dinner Table site on insurance.  You may find something helpful there.  I did see a sample letter that could be sent to an insurance company if a claim has been denied.

Sending warm support,
sk8r31
It is good to not only hope to be successful, but to expect it and accept it--Maya Angelou
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MBR
 I’m very grateful for you helping me research this. It helps me be better prepared since time is of an essence. Hopefully this is the reason why they denied unless it’s some type of protocol procedure reason. I didn’t realize it be this complicated to get my daughter Help.I thought all we had to do was prove justifiable  reasons why the other place didn’t work since we tried it twice. I was told by several people to get a patient care advocate Or a  or a care case manager  but it was nearly impossible to find one  and there was nothing listed in the general areas of information like member services. They are supposed to be the ones to help if you have any issues receiving care for medical reasons. It’s very confusing because Eating Disorder is considered a mental health issue even though there are problems that arise with the health  it’s put into a different category. That’s what a social worker told me. And he said he couldn’t help me for this reason or access the records since it’s not considered medical. It’s very strange and I don’t understand. I had two people that I know can’t wait for the care case manager  when they were admitted in the hospital but I guess it’s because their case is considered to be medical. It would’ve made it easier than having to jump through a lot of hoops to have someone help navigate the waters. What do you think about this? Thank you for all your time and help . I feel a lot more that’s less scared Knowing that I have a place to ask questions and vent my concerns . Thank you very much  for caring 
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ValentinaGermania
So maybe it would help to give us some ideas about the state of your d at the moment so we could help you with ideas to consider it "medical"?
Does she refuses meals or to drink? Is she severly underweight? Does she have abnormal heart rate/blood pressure? Has she seen a GP recently for a medical check up that could help?
Keep feeding. There is light at the end of the tunnel.
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