Team Up for Your Child

N E W S L E T T E R

Volume II

Managing Your Mental Health Insurance:

From Aggravation to Results

The single topic for this issue is how to get the most from your mental health insurance coverage. Health insurance has been in the news a lot lately with the re-authorization of the federal Children’s Health Insurance Program (CHIP) and the debate about expanding coverage to millions of uninsured Americans. However, even if you have a good policy, you can spend hours on the phone with customer service trying to find out why you got that denial letter filled with mysterious “comment codes” and other insuro-babble. Here’s a primer on what it all means, and how you can get what”s coming to you. With best wishes——Wendy Besmann

Health Insurance 101: The Basics

Benefits are payments made by an insurance company for services your child receives that covered by the insurance policy or health plan. Mental health benefits are often managed by a type of insurer called a Behavioral Health Organization (BHO). Often you may have one company managing your family’s physical health benefits and a separate company or division handling mental health benefit

.The decision to pay is made by a “utilization reviewer” (often a nurse or other medical professional) who works for the insurer.

How “Managed Care” Works

When a doctor or other clinician evaluates your child and recommends a treatment plan, you, as the parent, must agree to this plan ahead of time. If your child receives benefits, the insurance company will also get involved before treatment starts. Professionals hired by the company must agree ahead of time that the insurance plan’s guidelines (rules) do in fact cover those services. This process is called a utilization review, and the professionals who do this task (often nurses and social workers) are called utilization reviewers or case managers.

Sometimes another professional, such as a child psychiatrist, will review your child’s case if there are questions about what your child needs. You or your child’s treatment provider can request this added review when trying to change a decision about your child’s coverage. If the treatment is shown to fit the plan’s guidelines, the reviewer will authorize (agree to pay for) those services.

In the case of some benefits, such as psychotherapy, the insurance company will often authorize a certain number of sessions. Your child’s therapist will have to submit another treatment plan to get more sessions approved. Sometimes this process takes place with a phone call, but in other cases, written records have to be sent. Either way, number codes stand for certain kinds of services and reasons for needing services. Sometimes a claim can be denied because somebody accidentally used the wrong code or made a mistake entering the information into the computer.

Parents may need to get on the phone with staff in the behavioral health professional’s office or with someone at the insurance company to fix such errors. The insurance company that pays for services may do this review on its own, or it may use another BHO. If so, you may need to call one phone number to ask questions about benefits or solve problems and a different number for questions about billing. When problems occur, you may have to get in touch with that company using the customer service number on the ID card or in the member’s handbook. Look for the Mental Health/Substance Abuse (MH/SA) number on your insurance card.

Utilization reviewers have to answer three questions when making decisions: FIRST QUESTION: What’s NECESSARY? A child going through a psychiatric crisis may not need to be hospitalized if a program exists to treat those symptoms (less expensively and traumatically) while the child remains at home. In mental health, the different ways in which your child can receive care are grouped into 12 major treatment categories called the “continuum of care.” This continuum ranges from the least to the most comprehensive care environments. At one end of the continuum is an office or clinic visit (for example, with a psychiatrist or therapist). More involved is “intensive case management” in which specially trained individuals—including peer supporters in some programs—provide psychiatric, financial, legal, medical or therapeutic services that allow a child to live successfully at home or in the community. At the far end of this spectrum is full hospitalization. For a useful chart on continuum of care, go to www.aacap.org.

Two Words That Open Doors: “Medically Necessary.” Health insurance companies cover treatments that are medically necessary, a critical term that means the services are required in order to treat your child’s symptoms. When your child’s treatment team (that is, the doctors and other professionals who provide treatment services) want the insurers to approve services that aren’t usually covered, they have to show that the services are medically necessary. Sometimes you will have to get experts at the company (utilization reviewers higher up the chain) to review your child’s claim. WHen the provider uses the words “medically necessary” in a letter or call, it can really help.

SECOND QUESTION: What’s AVAILABLE? Not all continuum of care option may be available where you live. To find out more, survey the websites of local community mental health agencies and hospitals in your area. Another good source is your local NAMI affiliate. To find one near you, call the NAMI HelpLine at 800-950-6264 or go to www.nami.org.

THIRD QUESTION: What’s COVERED? Most insurance plans have exclusions, which are types of treatment the plan won’t pay for under certain conditions. You may have to pay a certain amount per year (called an annual deductible) before the health plan starts to pay. You may also have to pay a small amount (called a co-payment) for certain treatments. Your plan may also have an annual out- of-pocket maximum which is the highest amount of deductible or co-payment charges you have to pay in one year. On the other hand, the plan may also have an annual or lifetime maximum benefit which is the most the insurer will pay for a particular type of treatment over one year or during the whole time your child is covered by the health plan.

Keeping a phone log helps you track the problem, explain it more easily as you go up the chain, and have a physical record of your claim problem if you need to file an appeal.

Best Bet for Getting Results: Keep a Phone Log

The best way to succeed in getting treatment approved is to keep a phone log of “who said what and when.” This creates a physical record of your conversations if you need to go up the chain to a higher authority or file an appeal. It also helps you keep track of issues so you can explain the problem to the next person in the chain. Even mentioning you kept a phone log tends to get the attention of a customer service case manager. You can keep this log in an ordinary spiral notebook, but be sure to include the date (month, day, year and time) of the call, the name and job title of of the person you spoke with, the company, the phone number, the issue (what you wanted) and the response (what happened). Write neatly—you may need to show this log if you file an appeal.