Below are a few examples of denials that our clients have received from their insurance company. These clients (and countless others) have all been adversely affected by an insurance company's misunderstanding of what it means to be treated for, and recover from an eating disorder, an insurance company's misdirected and harmful attention to weight, and an insurance company's impact on terminating treatment before wellness has been restored.
"The goal of treatment is to gain more weight."
You went to this program because you are at a very low body weight. Your low weight has caused medical problems, but this has been treated. You are medically stable enough for treatment outside of a hospital. The goal of treatment is to gain more weight. This can be done without 24 hour supervision. You can be treated with outpatient services (denial for inpatient psychiatric hospitalization 12/6/11).
"Your weight has been stable. Your body weight has increased."
Your weight has been stable. Your body weight has increased. You no longer require constant supervision to stay at this weight or gain weight (denial residential treatment 3/25/10).
"You have been eating the amount recommended even though it causes anxiety. . ."
You went to this program because you were at a low body weight. This was starting to lead to serious medical problems. You have gained weight. Medical problems caused by your low weight have become stable. Your parent is not permitting the recommended treatment to be used. However, you have been eating the amount recommended even though it causes anxiety. You can be safely treated without 24 hour supervision. You can get eating disorder treatment using outpatient services (denial residential treatment 11/22/11).
"Your body weight is over 75% of normal for your size."
At this time, you can be safely treated outside of a hospital. You can continue your eating disorder treatment at a less restrictive setting. Your body weight is over 75% of normal for your size. You are medically stable. Your eating disorder behaviors are not causing medical problems that need hospital treatment (denial residential treatment 12/21/11).
Why is it important to move the focus away from weight?
Essentially, insurance companies have become experts in finding ways around the law, avoiding and delaying payment of claims, and leaving insureds fatigued and confused. Although it might come as a surprise to many insurance companies (and to those who have little experience with eating disorders), weight restoration is only one piece of the recovery journey. Without proper treatment, it is entirely possible for a patient to become weight restored - yet still lack the ability to maintain this weight outside of treatment…resorting to unhealthy (and oftentimes dangerous) behaviors. We have experienced many weight-based insurance denials, leaving our clients without access to the treatment they desperately need and deserve… and inevitably vulnerable to relapse.
According to the National Institute of Mental Health (NIMH), successful treatment of eating disorders involves three crucial components:
Failing to address every component of eating disorder treatment often means discharging patients too soon - without effective coping strategies, without the tools necessary for a life not including eating disorder behaviors, without the advantage of working with a team of eating disorder specialists. Weight-based insurance denials can generate unnecessary stress and recovery setbacks and relapse rates are startlingly high.
"Weight restoration is a necessary but not sufficient indicator of recovery," explains Dr. Lauren Muhlheim, Clinical Psychologist and Certified Eating Disorder Specialist in Los Angeles, Ca. "We know that it takes the brain much longer to recover from the effects of starvation. We definitely have all seen patients who are weight restored, but still cognitively impaired and preoccupied by their eating disordered thoughts. Recovery should be based on a number of other criteria, including behaviors and thoughts."
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Eating Disorders recommends that when determining a patient's level of care, or when deciding if a change to a different level of care is appropriate, rather than simply relying on one or more physical parameters (such as weight) it is important to consider the following:
In addition to clinical reasons for shifting the focus away from weight, it is also important for the patient to understand that health and wellness is not simply a number. When insurance companies place such significance on weight, this becomes a difficult task. Many patients feel that if their insurance company decides that they are not sick enough, that they are at a "normal" weight, or that they are medically stable, then perhaps they are not really that sick. Perhaps they don't really need treatment anymore. The truth is, eating disorders are complicated. In addition weight restoration; there are many underlying psychological issues, unhealthy coping skills, and serious medical complications to be tended to.
What can we do to reduce weight-based insurance denials?
We recommend that when treatment providers communicate with insurance companies, they:
If you have questions about how to best advocate for the insurance coverage for treatment of an eating disorder, or what to do in the event of an insurance denial, please do not hesitate to contact Kantor & Kantor, LLP for help. We offer free consultations and work on a contingency fee basis – meaning that we do not collect a fee unless we get your claim paid.
We understand and we can help.
www.kantorlaw.net (800) 446-7529