Appealing Insurance Denials

Notes from June 18th - Michael Lynch - Appealing Insurance Denials

• After calling the generic number of your insurer's customer service you will be bounced around until you find someone who can help you. When you find that person:
• Ask for their name, email address, and extension so you can contact them directly.
• Send them an email after your call summarizing your takeaways and asking them to correct anything you may have misunderstood
• Always keep a record of who you talked to, and what was said. You can use this information in your external review to show that you exhausted all options internally first.
• Remember that insurers, clinics and patients are all responding to incentives. The insurer has set up an arduous internal review process in order to make you give up on your claim. They may deny your claim unlawfully, but until you get through the internal appeal you cannot make your case to the regulator or the courts.
• Mental Health Parity and Addiction Equity Act (MHPAEA) - No limitation can be placed on medically necessary mental health treatment that are more restrictive than those placed on medical/surgical benefits. This means that the insurer cannot deny a claim for ABA services, for example, on the basis of age, number of hours, setting (read: school setting), or a "lack of progress".
• If you have a commercial health plan through your employer (group) then your insurance is regulated on a state level. File your complaint in the state in which the insurance was purchased (Check your Insurance Card). File Kansas complaints HERE
• In your appeal cite MHPAEA, state laws that the denial violates or recent case law that supports your argument.
• Example: "Sec. 356z.14. Autism spectrum disorders." Section (e) and (e-5) "An insurer may not deny or refuse to provide otherwise covered services under a group or individual policy of accident and health insurance or a managed care plan solely because of the location wherein the clinically appropriate services are provided"
• Example: Wit v. United - California court rules United Behavioral Health violated Illinois law by using its own guidelines instead of the mandated criteria
• Example: "Johns v Blue Cross Blue Shield of Michigan, Case No. 08-cv-12272"
• When arguing medical necessity cite the industry standard care as defined by practitioners, NOT insurers.
• Example: For ABA and Autism those guidelines are set by CASP
• When arguing medical necessity cite relevant research in the medical literature. Go to Google Scholar search for something like "ABA in a school setting" and read the abstract of papers until you find one that supports your position. Check the reference sections of those papers and read abstracts of papers that they cite. Pay attention to the citation count, the higher the count the more well known the result.
• Example: In the Journal of Behavior Modification Eikeseth et al. state: "Our results suggest that the intervention can be successfully adapted to school settings for some children with autism"
  • Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2002). Intensive behavioral treatment at school for 4- to 7-year-old children with autism: A 1-year comparison controlled study. Behavior Modification, 26, 49-68. doi:10.1177/0145445502026001004
• If your appeal is denied then you get to file an external review with the state. See "ThePlaybook" (attached) for details.
• When you eventually win, pay it forward by writing your local representatives to the state and federal government thanking them for their support. Succinctly explain the issue you faced with your insurer, and explain how the Mental Health Parity Act, or some state law got your child the care they needed.

Resources

• "Is That Legal Toolkit 2023" (attached) - Written by ABA lobbyist Julie Kornack with the Center for Autism. She details common denial reasons cited by insurers and the specific laws that they violate.
• "AutismLawSummit - ThePlaybook" (attached) - 112 page comprehensive guide through appealing "fully insured / commercial group" policy denials.
• Autism Law Summit - 3 day convention for ABA industry professionals

Scripture reflection: Deuteronomy 20:1 "When you go out to war against your enemies and you see horses and chariots and an army greater than your own, you shall not be afraid of them, for the LORD, your God, who brought you up from the land of Egypt, will be with you."