insurance appeal presentation, az autism coalition

Sue Lerner, Ph.D. www.drsuelerner.com 10/09


I hope you are enjoying the Conference! I'm sorry to miss it. I wasEager to attend many of the sessions. I’m wearing my ”parent hat”and I’m in Texas this weekend. My 18 year old daughter (with ASD) began college in June. It’s parenting weekend @ her transition program there. Also, she has several specialist doctor Appointments that I couldn't re-schedule. For those parents who’s kids with ASD are young, some things change & some don’t!

But, I want to convey a message of hope to you. After years of Struggles during K-12, my daughter’s transition to independenceis going well. She maintains her apartment, cares for herself, bicycles to community college, does her assignments and arranges taxis to therapy and other appointments.

The challenges posed by my daughter’s ASD do slow her down, and they limit her (by neuro-typical standards), but now, she's having HER life and it’s more on HER terms than ever before.

Anne enjoys doing well in her classes; she likes her life; she has passions (her artwork), but most of all, she has a range of emotions each day. This is especially new for her since she's been debilitated for years with anxieties and depression probably triggered by a confusing and overwhelming world. Now, my daughter has joy and she feels about the same amount of hope and "wonder" that other 18 years old feel. That restores my hope, and I hope this digression will bolster yours. Thanks for indulging this parent’s moment. I hope you don't mind. Enjoy the conference!

Sue Lerner, Ph. D (parent & licensed psychologist)


260.0 Million

SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of March 2007 CPS.

Know your plan. Do you need a referral from your PCP in order to see a specialist? Does your plan require prior authorization for a service such as a surgery or even OT

services? What services covered by your plan? What are the limits of the coverage? How many

sessions per week? Are small groups covered or does the work need to be 1:1? Are phone or other consultations covered?

In order for full coverage do you need to use an “in-network” provider? Does your plan cover “out-of-network” providers? If so, how much is covered and what are the limits of coverage? What is not covered? For example, in behavioral health, is residential treatment covered? At

what amount per day and for how long? In-network? Out-of-network?


If your plan denies a treatment or service, you will get an EOB stating the denial and the reason. Keep the EOB in a safe place.

Call the company that issued the denial. Have your EOB with you, the receipt from the denied service/procedure and your benefit plan details. In order for the denial to be overturned, you must ask to speak with a supervisor. The customer service representative can’t overturn the denial.

Mistakes happen. Several sources say that claims processing errors are common. One source stated that some insurance companies accept 20% error rate in claims processing (www.healthsymphony.com). Sometimes a re-submission or a re-processing of the claim will over turn the denial.

You can or should consider an appeal if:

The treatment isn’t a covered benefit, but you think the health plan should make an exception for you, or

You have support from your physician that the treatment is “medically necessary” or

The treatment is deemed by the insurance company to be experimental or investigational.

Consider the following steps:

Investigate the cause of the denial by reading your policy booklet and the reason for the denial. The policy booklet explains what is covered, by whom and how much is covered. If the booklet and the explanation on the EOB don’t match, call your health plan for a clarification.

Document all phone calls. Document the day, time, phone number, person. title and content of the call. If you find later that you were given inaccurate information, refer back to your notes of the call. Keep these records in your insurance file with other correspondence such the EOBs. Keep copies of any correspondence including claims that you send to your health plan company.


There are other explanations for denials. One common form of denial is due to “lack of medical necessity”. This may occur if the physician prescribes a treatment that is considered to be experimental, investigational, cosmetic, an off-label use of a medication or is listed as a non-covered benefit by the health plan. Many of the common services or treatments for symptoms of ASDs fall into this category since research for child behavioral health and research for autism treatments has been underfunded for many years. There just aren’t a lot of outcome studies yet!


Consider a “mounting” a written appeal. Managed care organizations are required by law to have an appeal process. Appeal process details often accompany the EOB, are available on the company website and in their written plan materials.

Follow the details of the appeal process and pay attention to the time limits.

Several sources suggest that you can bolster the appeal of a Medical Necessity Denial by sending detailed documentation supporting why the treatment is necessary. If your doctor, therapist or service provider has not already submitted a letter detailing the

recommendation and rationale, request this type of documentation. If the problem is long-standing or chronic, additional medical notes or assessment reports be helpful as well. It may help if your provider include copies of articles from established medical journals supporting the treatment.


Health plans differ in appeal details. Sometimes appeals involve paper review only whereby the appeal is limited to a review of written medical notes during treatment. If treatment is ongoing, this type of appeal may impose great financial burden to the family because they will be responsible for the treatment costs. If the appeal is successful, the family will be re-imbursed for the covered expenses. The patient may request an expedited appeal whereby a phone consultation is arranged between the service provider and a health plan professional . This procedure is sometimes called a “doc-to-doc” appeal.

Some managed care companies offer voluntary external review appeals

If you have exhausted all appeals available through your private health insurance company, you have 30 days to request an external, independent review. These appeals are referred to the AZ Dept. of Insurance or to a medical reviewer approved by the Insurance Dept. See www.id.state.az.us for details.


Why should you participate in employer provided health services when your family member qualifies for public health insurance?

o Economic “ups & downs” may undermine the security of some public services.

o Uncertainty about health care reform. Some choice may be limited.

o Broadest choice of best specialist providers. Best chance for a match between patient need and provider skills.


Your insurance company’s behavioral health “Level of Care Guidelines for Mental Health and Substance Abuse Treatment” manual. Usually a PDF file available online through your private insurance company’s website. This manual documents the criteria for your company’s continuum of care and levels of care. This is in addition to any manuals that you obtain each year when you renew your private insurance.

http://www.id.state.az.us/consumerlifehealth.html Consumer’s page of the AZ Dept. of Insurance. Consumer guides for various types of insurance as well as health care appeals.

http://www.insurancecompanyrules.org/pages/private_health_insurance_101 Website is a project of Health Care for America Now (HCAN), grassroots campaign dedicated to winning quality, affordable health care we all can count on in 2009. The website has tutorials, an extensive health insurance glossary, and details and critiques each state’s health insurance rules.


insurance appeal presentation, az autism coalition

Documents

health plan company

benefit plan details

noncovered benefit

common form of denial

treatment isnt

residential treatment

message of hope

child behavioral health