Tips to navigate insurance denials for mental health conditions [The Seattle Times]

Aug. 6—Receiving a denial letter from an insurance company for mental health care can put patients in a vulnerable position, forcing them to choose between forgoing treatment or paying for costs out of pocket — or spending time debating denials.

"The system is not what it should be and fails families on a regular basis," said David Lloyd, chief policy adviser at The Kennedy Forum, a mental health advocacy organization. "There needs to be a multifaceted approach to fixing this system, with much stronger rules, much stronger oversight, and a much more consumer-friendly process."

Often, and for good reason, people think the first "no" is their last chance. But advocates urge patients to explore their rights and resources.

Remember, if you or someone you know is experiencing a mental health crisis, you can call 988, the national, 24/7 mental health hotline. Native and Indigenous callers can press 4 to connect with a knowledgeable counselor.

Your rights

Under Washington state laws, health insurance plans are required to cover behavioral health services and treatments, like counseling, chemical dependency detoxification, prescription medication, skilled nursing facilities, and inpatient, residential and outpatient mental health and substance use disorder care.

National parity laws also mandate that health insurers provide the same level of benefits for mental health and substance use disorders as for medical and surgical services.

That means deductibles, co-payments and out-of-pocket maximum payments must apply equally to all services in a health plan. Benefits must cover prescription drugs to the same degree other medications are covered.

No categorical exclusions can apply for mental health and substance use disorder treatment, and services cannot be limited or denied based on age, condition or because treatment was interrupted or incomplete. U.S. military veterans can visit any facility for free emergency mental health care.

Appealing your denial

If you have sought mental health care or substance use disorder treatment and you feel you have been wrongfully denied coverage, you have a few options.

To start, "you can file a complaint and get your concerns reviewed with the company," said Karen Fessel, who founded the Mental Health and Autism Insurance Project.

Your insurance company must provide a written explanation for the denial, according to the state Office of the Insurance Commissioner. Make sure you read the letter and scan for any details about their timeline to complain.

Nearly 17% of in-network claims were denied in 2021 across insurers in the ACA marketplace with complete data, the health policy research organization KFF found. But appeals can be successful: Insurers for HealthCare.gov members reversed about 40% of denials upon appeal.

Insurers sometimes deny coverage because they consider treatments not medically necessary, experimental or out-of-network. The OIC suggests countering those rejections by showing you could not find a provider who had the specialty you needed in-network or there was an unreasonably long wait time. You could also provide evidence that the treatment you received was the only one that would work or that it was less expensive than other treatments.

Tiffany Ruegsegger, manager of clinical reviews at Premera, recommends reading the rejection fully to understand the reasons for denial, and gathering evidence not initially included to justify the treatment.

If you feel the explanation in the denial isn't sufficient, you can ask for more information from your insurance company. For example, you can inquire about treatment limits or the criteria the insurer used to determine medical necessity. A form is available through the Department of Labor website to make the request. Your insurer must respond within 30 days.

Additionally, you can file a formal appeal using your grievance rights as a member. Information about how to appeal should be available within the denial letter or by calling your insurer.

In your appeal letter, clearly describe the outcome you're seeking and include relevant medical records and supporting documents from your medical providers, the state advises. Examples of sample letters to insurance companies can be found on the OIC's website.

While you're awaiting an appeal decision, you can ask to delay payment on your charges or you can choose to pay and get reimbursed if the appeal is approved. And you can negotiate the amount owed, set up a payment plan or request that your medical provider not send bills to collections agencies.

You can also request an expedited appeal, which requires an insurance company to make a decision about your appeal within 30 days, if a provider determines your health is at risk.

If your appeal is denied

If your health plan upholds its claim denial, "you are often entitled to what's called an external review," Fessel said.

After a denial, you can request an additional assessment of your claims requests using an external independent review organization. IROs are third-party groups that provide "objective, unbiased medical determinations that support effective decision making, based only on medical evidence," according to the National Association of Independent Review Organizations. In Washington, cases are assigned to certified IROs by rotation. Insurance companies must follow the ruling of an IRO.

You can look up IRO decisions on the Office of the Insurance Commissioner's website and contact the OIC if you have by calling 1-800-562-6900.

Additional action

In addition to appealing decisions with insurance companies, consumers "should find out who regulates their health plan and file complaints with them," Lloyd said.

If you have a private, self-funded plan: U.S. Department of Labor

(You likely have this plan if you work at a large company like Amazon, Microsoft or Boeing)

300 Fifth Ave. Suite 1210, Seattle, WA 98104-2397

206-373-6750

If you have a public, self-funded plan: Centers for Medicare & Medicaid Services within the U.S. Department of Health & Human Services

(You likely have this plan if you are a state or local government worker)

701 Fifth Ave. Suite 1600, Seattle, WA 98104

206-615-2306

If you have a fully insured small or large group plan: state Office of the Insurance Commissioner

(You likely work at a mid-size business)

302 Sid Snyder Ave. SW, Suite 200, Olympia, WA 98501

360-725-7171

To file a complaint to the state, go to the OIC's website and click "Complaints & appeals" under the Consumers tab. Cases should be reviewed within 45 days, but the timeline may take longer because of a backlog, the state says.

The OIC has the power to enforce parity for insurers under its regulation and can even prohibit a company from operating in the state.

You can file a complaint for any issues relating to service or treatment, including issues accessing in-network providers, benefit limits, and denials or services, medication or telemedicine.

The OIC does not regulate Medicare or Medicaid plans, TRICARE, plans provided for government or educational workers in the state, or self-funded plans, often held by people who work at large employers like Amazon and Microsoft.

Those self-funded plans are required to draft a report annually about their compliance with parity regulations, which can be requested by members, said Ellen Weber, senior vice president of health initiatives at the Legal Action Center.

Ultimately, "Some people have to hire attorneys, which is obviously very costly and that shouldn't be how our system is enforced," Lloyd said. But "that can often be a step that's needed, particularly with large amounts of money at stake."

The Northwest Health Law Advocates, the Washington Autism Alliance and the Mental Health and Autism Insurance Project can offer resources and support.

Volunteers with the Statewide Health Insurance Benefits Advisors offer free and confidential information to help people with their Medicare questions at 800-562-6900.

To find out more information about whether your insurer is complying with the law, you can visit The Kennedy Forum's website or go to dontdenyme.org.

More Seattle Times and Mental Health Project resources to help find a therapist:

* Trying therapy for the first time? Here's what to expect

* Having trouble finding a therapist in the Seattle area? Here are some tips.

* Hitting roadblocks while looking for a therapist? Here are some additional options

* Helping someone in a mental health crisis in WA: What to know

* Where to find diverse mental health resources in Seattle

* LGBTQ+ mental health resources in Seattle and King County

* King County and Washington mental health resources

More mental health insurance resources

* SAMHSA's Guide to Understanding Parity

* CMS's Guide to MHPAEA Protections

* NAIC's Guide to Parity for Insurers

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