lisa s. kantor, esq. kantor & kantor (877) 783-8686 [email protected]
DESCRIPTION
WORKING WITH INSURANCE COMPANIES TO OBTAIN COVERAGE FOR APPROPRIATE TREATMENT FOR EATING DISORDER CLIENTS. Lisa S. Kantor, Esq. Kantor & Kantor (877) 783-8686 www.KantorLaw.net [email protected]. OUR ROADMAP. Communication Fundamentals Different Types of Health Insurance - PowerPoint PPT PresentationTRANSCRIPT
Lisa S. Kantor, Esq.Kantor & Kantor(877) 783-8686
WORKING WITH INSURANCE COMPANIES TO OBTAIN COVERAGE FOR
APPROPRIATE TREATMENT FOR EATING DISORDER CLIENTS
www.KantorLaw.net 2
www.KantorLaw.net 3
OUR ROADMAP
Communication Fundamentals
Different Types of Health Insurance
Required Claims Procedures Using the APA Guidelines Getting Eating Disorder
Claims Paid
www.KantorLaw.net 4
Communication Fundamentals Write down what you are going to say before any
telephone call with an insurance representative Write down everything that is said in any
conversation with an insurance representative Know the name, title, phone number and email
address of everyone you talk to Send everything in – medical records, therapy
notes, notes of conversations, letters of support Confirm everything in writing because if it isn’t in
the insurance company’s file, it may as well not exist
Certified mail if possible, e-mail is ok Have clients journal on insurance issues
www.KantorLaw.net 5
Health InsuranceTwo different types:
Benefits obtained through an Employer (even if you pay some or all of the premium) – covered by the Employee Retirement Income Security Act (ERISA) [Note: Does not apply to government or “church” employees]
A policy purchased privately, through an insurance agent.
www.KantorLaw.net 6
Employer Benefits – ERISA
ERISA is a federal law that governs the insured’s rights If a claim is denied, an appeal (or maybe two) must be
timely filed before the insured can file a lawsuit Great deference may be given to the decisions of the
insurance company No jury trials Federal judges make decisions if you have to file suit
to get benefits The judge will review the contents of the insurance
company’s file and very little else Remedies are limited to benefits and attorneys fees
www.KantorLaw.net 7
Individual Insurance
Typically no appeals required before a lawsuit can be filed
Juries (not lifetime appointee judges) make the decision on your case
Evidence outside of the file may be considered by the jury
Remedies may include benefits, emotional distress, attorneys fees and punitive damages
www.KantorLaw.net 8
Important Differences Between ERISA and Individual Coverage
ERISA Plans:
No individual underwriting
Cheaper – and your employer may pay
Remedies restricted
Individual Coverage:
Individually medically underwritten
More expensive and you pay all the premium
Bad faith remedies available in many states
www.KantorLaw.net 9
How did you get your coverage?
through my, or my spouse’s, or my
parent’s employment
Who is your employer?
Government, religious entity
All others
private purchase
www.KantorLaw.net 10
INSURANCE BY ANY OTHER NAME..
What is a Plan?
Fiction created by ERISA whenever an employer offers health or welfare benefits
May be funded by a policy or by the employer
May be the same as the Policy or a different document
What is a Policy?
Insurance to cover certain risks or expenses
Not the same as certificate or evidence of coverage
www.KantorLaw.net 11
THE INSURANCE CARD IS NOT ENOUGH…
What kind of coverage does this person have?
www.KantorLaw.net 12
HOMEWORK FOR THE CLIENT
Send a letter to Human Resources to request a copy of the Plan document
Send a letter to the Insurance Company to request a copy of the Policy
Get copies or CD of your medical records Get letter(s) of support from treating
physicians, therapists, dieticians, family, co-workers, friends
Home video Complete a HIPPA release
www.KantorLaw.net 13
Required Claims Procedures29 C.F.R. § 2560.503-1
Procedures must be reasonable Everything must be in writing – procedures,
denials, appeal denials Procedures must be given to the participant
Must include prior approval, preauthorization, and utilization review procedures
Cannot require more than two appeals
www.KantorLaw.net 14
Required Claims Procedures29 C.F.R. § 2560.503-1
Cannot contain any provision, or be administered in any way, that “unduly inhibits or hampers the initiation or processing of claims” FOR EXAMPLE, “the denial of a claim for failure to
obtain a prior approval under circumstances that would make obtaining such prior approval impossible or where applicable of the prior approval process could seriously jeopardize the life or health of the claimant . . .”
www.KantorLaw.net 15
Required Claims Procedures29 C.F.R. § 2560.503-1
Concurrent care claims: Any reduction or termination of an ongoing
course of treatment must be done far enough in advance to allow the patient to appeal and obtain a review before the benefit is terminated
Any request to extend an ongoing course of treatment shall be decided within 24 hours provided the request is made 24 hours prior to expiration of the approved treatment
www.KantorLaw.net 16
Required Claims Procedures29 C.F.R. § 2560.503-1
Pre-service claims: Must respond within 15 days May extend time once for 15 days for reasons
“beyond the control of the plan” and notification is given before first 15 days expires
If plan needs additional information, patient must be given 45 days to provide
www.KantorLaw.net 17
Required Claims Procedures29 C.F.R. § 2560.503-1
Post-service claims: Must respond within 30 days May extend time once for 15 days for reasons
“beyond the control of the plan” and notification is given before first 30 days expires
If plan needs additional information, patient must be given 45 days to provide
www.KantorLaw.net 18
Appeals Must provide a full and fair review Entitled to review claim file Must consider all comments, records, other
information submitted by patient No deference to original decision Cannot be decided by same person who denied
claim Must consult health care professional with
appropriate training and experience who was not consulted in connection with denial
Must identify professionals consulted
Required Claims Procedures29 C.F.R. § 2560.503-1
www.KantorLaw.net 19
Appeals Urgent appeals must be decided in
72 hours The appeal decision must comply
with the notice requirements of the denial decision
Required Claims Procedures29 C.F.R. § 2560.503-1
www.KantorLaw.net 20
Required Claim Procedures What the Courts Say
“. . .ERISA imposes higher-than-marketplace quality standards on insurers. It sets forth a special standard of care upon a plan administrator, namely, that the administrator “discharge [its] duties” in respect to discretionary claims processing “solely in the interests of the participants and beneficiaries” of the plan, . . . it simultaneously underscores the particular importance of accurate claims processing by insisting that administrators “provide a ‘full and fair review’ of claim denials.” Metropolitan Life Ins. Co. v. Glenn, 128 S.Ct. 2343, 2350 (2008).
www.KantorLaw.net 21
Required Claim Procedures What the Courts Say
In simple English, what this regulation calls for is a meaningful dialogue between ERISA plan administrators and their beneficiaries. If benefits are denied in whole or in part, the reason for the denial must be stated in reasonably clear language, with specific reference to the plan provisions that form the basis for the denial; if the plan administrators believe that more information is needed to make a reasoned decision, they must ask for it. There is nothing extraordinary about this; it's how civilized people communicate with each other regarding important matters.” Booton v. Lockheed Medical Benefit Plan, 110 F.3d 1461 (9th Cir. 1997).
www.KantorLaw.net 22
www.KantorLaw.net 23
AMERICAN PSYCHIATRIC ASSOCIATION GUIDELINES
Sets the standard of care in the community
Used by Independent Review Panels Require interaction with patient to
assess Relies upon knowledge and
experience of treating professionals
www.KantorLaw.net 24
AMERICAN PSYCHIATRIC ASSOCIATION GUIDELINESMedical status
www.KantorLaw.net 25
SuicidalityAMERICAN PSYCHIATRIC ASSOCIATION GUIDELINES
www.KantorLaw.net 26
Weight
AMERICAN PSYCHIATRIC ASSOCIATION GUIDELINES
www.KantorLaw.net 27
Motivation
AMERICAN PSYCHIATRIC ASSOCIATION GUIDELINES
www.KantorLaw.net 28
Co-occurring disorders
AMERICAN PSYCHIATRIC ASSOCIATION GUIDELINES
www.KantorLaw.net 29
Needed Structure
AMERICAN PSYCHIATRIC ASSOCIATION GUIDELINES
www.KantorLaw.net 30
Compulsive exercising
AMERICAN PSYCHIATRIC ASSOCIATION GUIDELINES
www.KantorLaw.net 31
Purging
AMERICAN PSYCHIATRIC ASSOCIATION GUIDELINES
www.KantorLaw.net 32
Environment
AMERICAN PSYCHIATRIC ASSOCIATION GUIDELINES
www.KantorLaw.net 33
Availability of program
AMERICAN PSYCHIATRIC ASSOCIATION GUIDELINES
www.KantorLaw.net 34
www.KantorLaw.net 35
GETTING EATING DISORDER CLAIMS PAID
Submit pre-service request for treatment Use the APA Guidelines to document level of care
requested Submit prior and current treatment records which
support level of care requested Getting letters of support as needed, consider
patient video Explain eating disorders – use references Explain your program and the qualifications of the
providers Set boundaries
www.KantorLaw.net 36
HOW TO CONDUCT AN INSURANCE CALL
“I am calling from Avalon Hills Treatment Center in Logan, Utah. I am calling to request thirty days of residential treatment for your insured, Jane Smith. Jane is ill, and I am sure that when you hear about her journey, you will authorize the treatment.”
Introduce yourself, state your credentials, and ask for their credentials.
Confirm that your information was received; offer to e-mail or fax and wait for receipt
Tie the discussion to the specific criteria identified by the APA and/or the insurer
Emphasize the criteria that support the level of care you seek or a higher level of care
www.KantorLaw.net 37
NOW CLOSE THE DEAL . . . What is your name? How can I contact you? How would you
like us to send you information (mail or e-mail)? What address? What are your qualifications?
Do you have any questions? NO
Do you need any more information? NO
Are there any policy provisions or exclusions that would affect coverage? NO
Is there anything I should know about your procedures? NO
Will you authorize thirty days? YES
www.KantorLaw.net 38
…AND CONFIRM THE DEAL The same day, send a letter to the
plan/insurer confirming the entire conversation
If the person you spoke with will not give you her/his name or address, send it to the address in the plan/policy
Certified mail if you can
www.KantorLaw.net 39
…OR CONFIRM THE DENIAL The same day, send a letter to the
plan/insurer confirming the entire conversation
If the person you spoke with will not give you her/his name or address, send it to the address in the plan/policy
Certified mail if you can
www.KantorLaw.net 40
CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
www.KantorLaw.net 41
THE APPEAL
Now we are really having some fun …
www.KantorLaw.net 42
THE LAW OF ERISA APPEALS There are two critical things to know
about ERISA appeals
The insured is entitled to a copy of the claim file – sometimes called the administrative record – before the appeal is decided
The insurer or plan may be entitled to discretion in deciding the appeal
www.KantorLaw.net 43
WHAT IS THE CLAIM FILE AND HOW DO I GET IT?
The claim file consists of any document, record or other information that was relied upon in making the benefit decision, was submitted, considered or generated in the course of making the benefit decision, or is a statement of policy or guidance with respect to the plan concerning the denied treatment (29 C.F.R. Section 2560.503-1(m)(8))
The insured is entitled, upon request and free of charge, a copy of the claim file (29 C.F.R. Section 2560.503-1(h)(2)(iii))
www.KantorLaw.net 44
PLAN DISCRETION: THE FOX GUARDING THE HEN HOUSE
Many plans/policies provide that the entity deciding whether to pay claims has the “discretionary authority” to construe and interpret the Plan and determine eligibility for benefits
This means that the court will give deference to the decision of the Plan or insurer – the decision DOES NOT HAVE TO BE RIGHT, IT ONLY HAS TO BE REASONABLE
BUT when the same entity is deciding whether to pay claims, and is paying approved claims, the Supreme Court says there is an “inherent” or “structural” conflict (Metropolitan Life Ins. Co. v. Glenn, 128 S.Ct. 2343 (2008))
www.KantorLaw.net 45
The fox guarding the hen house (continued)
A "structural" conflict of interest introduces an element of skepticism into what would otherwise be deferential judicial review.
The degree of skepticism depends on the extent of the conflict. The types of evidence tending to show the influence of a conflict include: inconsistent or insufficient reasons for the denial determining a material fact without supporting evidence failing to follow plan procedures failing to provide a full and fair review of the denial acting as an adversary bent on denying the claim
The more evidence of conflict, the less deference afforded to the administrator, and the more "skeptical" the review
www.KantorLaw.net 46
WRITING THE APPEAL LETTER
This letter is submitted in support of Jennifer’s appeal of the denial of continued residential treatment beyond March 8, 2009. We will explain the history of Jennifer’s disease and treatment. We trust that, after reading this letter, which carefully documents Jennifer’s need for continued inpatient treatment, you will approve Jennifer’s request to continue that treatment.
Summarize the prior letters and documents Point out the inconsistencies Point out the irregularities Point out the omissions Enclose any new documents
Consider articles on eating disorders, or specific grounds to denial Conclude with specific requests
www.KantorLaw.net 47
WHAT TO DO IF THE APPEAL IS DENIED. . .
Second Level Appeal
Department of Insurance
Department of Management Healthcare
Litigation
Press
www.KantorLaw.net 48
Lisa S. Kantor, Esq.Kantor & Kantor(877) 783-8686
WORKING WITH INSURANCE COMPANIES TO OBTAIN COVERAGE FOR
APPROPRIATE TREATMENT FOR EATING DISORDER CLIENTS