Sue Lerner, Ph.D.  10/09
Sue Lerner, Ph.D.  10/09 I hope you are enjoying the Conference! I'm sorry to miss it. I was Eager to...
<ul><li>The challenges posed by my daughter’s ASD  do  slow her down, and they limit her (by neuro-typical standards),  bu...
260.0 Million SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of March 2007 CPS.
Sue Lerner, Ph.D.  10/09
Sue Lerner, Ph.D.  10/09
Sue Lerner, Ph.D.  10/09
Sue Lerner, Ph.D.  10/09
Sue Lerner, Ph.D.  10/09
Sue Lerner, Ph.D.  10/09
Sue Lerner, Ph.D.  10/09
Sue Lerner, Ph.D.  10/09
<ul><li>Know your plan.  </li></ul><ul><ul><li>Do you need a referral from your PCP in order to see a specialist?  </li></...
<ul><li>If your plan denies a treatment or service,   you will get an EOB stating the denial and the reason. Keep the EOB ...
<ul><li>There are other explanations for denials. One common form of denial is due to “lack of medical necessity”. This ma...
<ul><li>Consider a “mounting” a written appeal. Managed care organizations are required by law to have an appeal process. ...
<ul><li>Health plans differ in appeal details. Sometimes appeals involve  paper review  only whereby the appeal is limited...
Sue Lerner, Ph.D.  10/09
<ul><li>Why should you participate in employer provided health services when your family member qualifies for public healt...
<ul><li>Your insurance company’s behavioral health  “Level of Care Guidelines for Mental Health and Substance Abuse Treatm...
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Insurance Appeal Presentation, AZ Autism Coalition


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Presentation at AZ Autism Coalition Insurance Conference, October, 2009. Phoenix, AZ

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  • Now that Stephen’s Law is in effect, there is more need than ever for conversations about health insurance. Undoubtedly you’ve heard about health care reform furor of late. You may have heard that some of the obstacles to the reform effort stem from some of the complexities of the health care system. Health insurance is only one part of the health care reform initiative, nevertheless it is arguably the most complex of parts. The following presentation is about the health insurance system. The purpose of this conversation is clarification and simplification . This is not about reform or change. The purpose of this hour will be to give you the tools to understand the necessary details of your private health insurance plan in order to access the services that you are paying health premiums for. Additionally, we will highlight other resources available if your insurance company continues to deny your claim or your request for a health care service. Sue Lerner, Ph.D. 10/09
  • According to this recent data from Kaiser Family Foundation, about 18 % of the non-elderly population of US is uninsured and about 16%of the non-elderly receive coverage from Medicaid or other public sources. Sixty-six percent of the non-elderly citizens have private health insurance plans and the vast majority of these plans are employer-sponsored health insurance plans. To be clear, that’s 62% of the non-elderly population participates in employee –sponsored health insurance. obtain health insurance coverage through their employer. (about 62%). In the following presentation, we will be talking about these employer-sponsored health insurance policies.
  • It’s well known that people with special needs and with ASDS in particular have more need for medical and behavioral health services than the general population. People on the spectrum and their families consult with medical professionals for the typical reasons such as preventative health care and illness but they also require therapies and treatments for the challenges and needs that are more specific to the autism community such as ABA, OT, speech and a myriad of other services. It’s necessary for you as stakeholders to be informed consumers of the benefits and limits of your private health insurance plans . Here’s another area of expertise to add to your ever-expanding, ” impacted by ASD family resume ”. Maybe you’ve mastered a system of communication with your loved one on the spectrum. Maybe you’ve wrapped your head around his/her repetitive / restricted interests. Hopefully, you and your family are even having one of those non-crisis, periods. In any case, We empathize. We’ve been there and we’re still there. But, here’s another thing to get on top of. The private health care system is yet another one of those skill set that you need. Here’s how this next hour will be organized: Start with Terms To Know. You thought medical speak was/is hard to learn, insurance-speak is not just new words, there is a huge hidden curriculum in the health care industry. Standing in front of family members whose loved ones struggle with the hidden curriculum of our social world, we could make some very bad jokes about the frustrations, anger, confusion, helplessness, hopelessness and craziness we’ve felt trying to get health care covered for our loved ones with ASD and for ourselves when we need behavioral health care. More on that later! After getting up to spend on terms, we’ll clarify the types of insurance plans and the basic differences among them. We’ll spend most of the time talking about managed care because these are the types of plans that most of the employers offer now. We’ll then detail what to do when your health insurance company denies your request for a service or benefit. We’ll wrap this up with the resources to turn to after you’ve exhausted your company’s appeal process. Towards the end we’ll be talking about why, even with limitations employer-provided health insurance may well be an important resource for families with ASD even when they qualify for maximum public benefits. We’ll end our presentation with questions. Sue Lerner, Ph.D. 10/09
  • Behavioral Health Health services are classified into medical, dental and behavioral services. Mental health care is called behavioral health care. Except for neurologists and neuro-surgeons, professionals that treat neurological, neuro-developmental and neurobiological disorders are all considered behavioral health providers in the managed health care system. Medical, dental, vision and behavioral care services may differ in health plan coverage and claim systems . For example, while insurance cards may offer one phone number for medical and behavioral health claims, calls may be routed to offices that function separately. Information regarding a health plan’s behavioral health policies and coverage has historically been somewhat difficult to access. It has improved recently. Check your health plan benefits information carefully for the details of behavioral health coverage. Some plans have little of no behavioral health coverage. Limits in behavioral health coverage has been a mechanism for health insurance companies to contain costs. Depending on the plan, this may or may not change with recent legislation. Furthermore, even with adequate behavioral health coverage, other long-standing practices may continue to make reimbursements for services difficult. Common services for ASDs are usually classified as behavioral services ( ABA, psychiatric &amp; psychological evaluations and treatments, speech, OT, neuropsychological evaluations and others. Most of the services utilized by families with autism spectrum are behavioral health services. If you don’t already know this, keep this in mind because even services from some medical doctors such as psychiatrists are classified as behavioral health rather than medical services. Access to specialists in behavioral health may be more difficult than with the dental or medical services. You may have noticed many esteemed psychiatrists, psychologists or other specialized professionals in your community are not “in-network” providers on your managed care health plan. It has recently come to light that private insurance companies have utilized discriminatory practices in reimbursement rates to providers of behavioral health services. Many experienced behavioral health professionals (psychologists, psychiatrists and others) no longer participate as providers in managed care insurance plans. In some communities, it may be difficult or impossible to find appropriate experienced “in network” specialists for ASD or other behavioral health problems. What services are covered and the amounts of coverage differs for the 3 types. Medical, dental and behavioral health coverage differs. You may have noted this with your dental or even vision coverage. If you’ve changed managed care insurance companies recently, you may have called you primary care physician, your dentist and your optometrist to check to see if they are in-network providers in your new plan. You would also do the same for any behavioral health specialist such as psychiatrist, psychologist, speech, OT or other professional. How does an insurance company determine what treatments or procedures will be covered? It’s called “Evidence-based”. This means that there a practice of procedure has been shown by scientific research to be beneficial/therapeutic. Managed care insurance companies (gov’t, non-profit and for-profit companies) all use this practice to determine whether or not a treatment or procedure will be covered or reimbursed by their health plan. Most of the common medical treatments and procedures that we think of whether it is a “Z-Pak” of antibiotic for an infection or “tubes in the ears” of young children who are prone to ear infections, are commonly covered treatments because studies have shown some effectiveness. When there is insufficient research data demonstrating effectiveness of a procedure or treatment, the treatment is considered “ experimental” or “off-label”. Health insurance plans often contain costs by limiting coverage to “evidence-based” practices for particular conditions or diseases. Experimental or off-label treatments or procedures may not be covered. We know that there hasn’t been a lot of outcome research for treatment and procedures for ASDs. Researchers are working hard to catch up. Recently, large amounts of research dollars are going to ASD research. As new information comes to light, coverage for treatments will increase. At the present time, we need to be informed consumers of treatments and procedures. Sometimes, we may even have to inform insurance companies of recent findings. More on this in a later slide Health plans have limited services and reimbursements for behavioral health care. As health care costs continue to rise, health insurance companies have limited costs every way possible. Limits to benefits on behavioral health coverage is one way for profit health insurance companies contain their costs. Some plans don’t offer coverage; historically some plans limit the types and amounts of covered services. Stephan’s Law was necessary in AZ because insurance companies were excluding treatments for ASDs. The Wellstone-Domenici Mental Health Parity Act (to take effect Jan., 2010) is another important example of a trend to stop some of the discriminatory practices of for-profit insurance companies and behavioral health insurance benefits. This parity legislation (January, 2010) mandates improvements in behavioral health coverage. Unlike previous federal legislation, this parity law will apply to all financial requirements of insurance companies vis-à-vis behavioral health coverage. While the federal parity law does not prohibit companies from excluding certain diagnoses from coverage such as ASDs, it mandates improved access and equity for behavioral health care in many helath insurance plans. Health plan systems differ for different types of care. Don’t assume that the off ice that you’ve called for pre-certification for a medical procedure is that same office or company that you’ll speak to about behavioral health insurance issues. Differing systems within healthcare function independently. You may have to give your ID many times on 1 phone call. One phone call can take a very long time. If you get disconnected, you may have to go through the same long process to get to the behavioral health care system. For written information be sure that the address, fax or phone number for behavioral health claims and questions. Sue Lerner, Ph.D. 10/09
  • Sue Lerner, Ph.D. 10/09
  • Sue Lerner, Ph.D. 10/09
  • Sue Lerner, Ph.D. 10/09
  • Sue Lerner, Ph.D. 10/09
  • All health insurance is different. Unlike some consumer products, there’s no standard federal definition of what health insurance must cover. A few states define standardized policies that must be sold but more often, states pass mandated benefits laws that require specific services- such as mammograms- to be included in insurance policies.( This allows insurers considerable flexibility to design the benefits package. When you think of a health insurance plan, you probably have your own idea of what should be included. Many people believe that health care benefits should cover all necessary care, including preventative services and treatment needed for those with serious and chronic diseases and conditions. Those of you who have private health insurance, carefully review what your plan covers. This information is included in your benefits material from your employer or the employer who sponsors your plan. If you have misplaced the material, it is usually available online through the employer’s HR website. In my experience, it has been sometimes difficult to access details regarding benefits for behavioral health problems. This can be particularly important to families with ASD because most of the services, treatments and procedures for ASDs are considered behavioral health services and not medical services “ Typical” employer-sponsored health benefits are generally more comprehensive than individual or small group coverage. Employer-sponsored plans often included coverage for hospitalization, physician care, maternity care, prescription drugs, and other services. Individual health insurance policies may vary tremendously, but they tend to offer considerable less coverage for maternity and behavioral/mental health care and prescription drugs. Individual health insurance plans are not the focus of this presentation. For basic information regarding these these types and the many other types such as major medical, accident only and others, AZ Dept. of Insurance has a consumer’s guide to Group Health Insurance in AZ on their website at Until about 20 years ago, most people who had private health insurance had indemnity policies, which reimbursed you for covered services regardless of where you received care. You were not restricted to a network of specific providers. Now , most people with private health insurance have some form of “managed care”. In managed care plans medical, dental, and behavioral health care providers have a contractual agreement with the insurance company. In return for patient referrals, these in-network providers agree to provide services at a discount to the health plan participants. The rationale for this may be likened to the “volume discount” For example, a session of speech therapy might typically cost $120 per hour in a city, but a “in network” speech therapist may have agreed to a discounted $100 reimbursement rate directly from the managed care company. The therapist accepts the reduced fee per client because the insurance company restricts the number of speech therapists allowed on the network. This system channels patients with managed care plans to the network providers. There are several types of managed care plans : the Health Maintenance Organization (HMO) and the preferred provider and the point-of-service (POS) plans. HMOs provide health care services directly to their members while their members pay a fixed monthly fee to the HMO. The HMO is an alternative to traditional health insurance because it provides actual services rather than just reimbursement for health care expenses. Usually, HMO members must receive health care treatment at a designated hospital, HMO facility or from particular physicians or professionals who contract with the HMO. Before you pay a fee to join an HMO, ask about how it works, what specialists and services are covered. Consider whether you will have to stop your treatment with a particular physician or professional. Most HMOs do not pay for services received from non-network professionals. When a managed care company offers Preferred Provider Organizations (PPOs) plan, selected doctors, professionals, and hospitals have contracts with the insurance company. As a member of a PPO plan, your plan benefits include health care from a preferred or in-network medical professional where you pay a small co-pay or co-insurance and the insurance company pays the remainder of the negotiated fee. Your PPO benefits may also allow you to receive health care from an non-preferred or out-of-network provider but you will have to pay a higher deductible and/or copayment. In these circumstances, you typically pay the entire cost of the service at the time of the appointment and you file an insurance claim for reimbursement from the insurance company. A point-of-service plan combines the benefits of an HMO and traditional health insurance. Enrollees can use providers in the HMO for a nominal co-payment or seek care outside the HMO network where a deductible and a share of the cost will most likely have to be paid. Sue Lerner, Ph.D. 10/09
  • Sue Lerner, Ph.D. 10/09
  • Sue Lerner, Ph.D. 10/09
  • Sue Lerner, Ph.D. 10/09
  • The AZ Dept. of Insurance offers a free brochure details how the Health Care Appeals process works. Sue Lerner, Ph.D. 10/09
  • Sue Lerner, Ph.D. 10/09
  • Sue Lerner, Ph.D. 10/09
  • Insurance Appeal Presentation, AZ Autism Coalition

    1. 1. Sue Lerner, Ph.D. 10/09
    2. 2. Sue Lerner, Ph.D. 10/09 I hope you are enjoying the Conference! I'm sorry to miss it. I was Eager to attend many of the sessions. I’m wearing my ”parent hat” and I’m in Texas this weekend. My 18 year old daughter (with ASD) began college in June. It’s parenting weekend @ her transition program there. Also, she has several specialist doctor Appointments that I couldn't re-schedule. For those parents who’s kids with ASD are young, some things change & some don’t! But, I want to convey a message of hope to you. After years of Struggles during K-12, my daughter’s transition to independence is going well. She maintains her apartment, cares for herself, bicycles to community college, does her assignments and arranges taxis to therapy and other appointments.
    3. 3. <ul><li>The challenges posed by my daughter’s ASD do slow her down, and they limit her (by neuro-typical standards),  but now, she's having HER life and it’s more on HER terms than ever before. </li></ul><ul><li>Anne enjoys doing well in her classes; she likes her life; she has passions (her artwork), but most of all, she has a range of emotions each day. This is especially new for her since she's been debilitated for years with anxieties and depression probably triggered by a confusing and overwhelming world. Now, my daughter has joy and she feels about the same amount of hope and &quot;wonder&quot; that other 18 years old feel. That restores my hope, and I hope this digression will bolster yours. Thanks for indulging this parent’s moment. I hope you don't mind. Enjoy the conference! </li></ul><ul><li>Sue Lerner, Ph. D (parent & licensed psychologist) </li></ul>Sue Lerner, Ph.D. 10/09
    4. 4. 260.0 Million SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of March 2007 CPS.
    5. 5. Sue Lerner, Ph.D. 10/09
    6. 6. Sue Lerner, Ph.D. 10/09
    7. 7. Sue Lerner, Ph.D. 10/09
    8. 8. Sue Lerner, Ph.D. 10/09
    9. 9. Sue Lerner, Ph.D. 10/09
    10. 10. Sue Lerner, Ph.D. 10/09
    11. 11. Sue Lerner, Ph.D. 10/09
    12. 12. Sue Lerner, Ph.D. 10/09
    13. 13. <ul><li>Know your plan. </li></ul><ul><ul><li>Do you need a referral from your PCP in order to see a specialist? </li></ul></ul><ul><ul><li>Does your plan require prior authorization for a service such as a surgery or even OT services? </li></ul></ul><ul><ul><li>What services covered by your plan? What are the limits of the coverage? How many sessions per week? Are small groups covered or does the work need to be 1:1? Are phone or other consultations covered? </li></ul></ul><ul><ul><li>In order for full coverage do you need to use an “in-network” provider? </li></ul></ul><ul><ul><li>Does your plan cover “out-of-network” providers? </li></ul></ul><ul><ul><li>If so, how much is covered and what are the limits of coverage? </li></ul></ul><ul><ul><li>What is not covered? For example, in behavioral health, is residential treatment covered? At what amount per day and for how long? In-network? Out-of-network? </li></ul></ul>Sue Lerner, Ph.D. 10/09
    14. 14. <ul><li>If your plan denies a treatment or service, you will get an EOB stating the denial and the reason. Keep the EOB in a safe place. </li></ul><ul><li>Call the company that issued the denial. Have your EOB with you, the receipt from the denied service/procedure and your benefit plan details. In order for the denial to be overturned, you must ask to speak with a supervisor. The customer service representative can’t overturn the denial. </li></ul><ul><li>Mistakes happen. Several sources say that claims processing errors are common. One source stated that some insurance companies accept 20% error rate in claims processing ( ). Sometimes a re-submission or a re-processing of the claim will over turn the denial. </li></ul><ul><li>You can or should consider an appeal if: </li></ul><ul><li>The treatment isn’t a covered benefit, but you think the health plan should make an exception for you, or </li></ul><ul><li>You have support from your physician that the treatment is “medically necessary” or </li></ul><ul><li>The treatment is deemed by the insurance company to be experimental or investigational. </li></ul><ul><li>Consider the following steps: </li></ul><ul><li>Investigate the cause of the denial by reading your policy booklet and the reason for the denial. The policy booklet explains what is covered, by whom and how much is covered. If the booklet and the explanation on the EOB don’t match, call your health plan for a clarification. </li></ul><ul><li>Document all phone calls. Document the day, time, phone number, person. title and content of the call. If you find later that you were given inaccurate information, refer back to your notes of the call. Keep these records in your insurance file with other correspondence such the EOBs. Keep copies of any correspondence including claims that you send to your health plan company. </li></ul>Sue Lerner, Ph.D. 10/09
    15. 15. <ul><li>There are other explanations for denials. One common form of denial is due to “lack of medical necessity”. This may occur if the physician prescribes a treatment that is considered to be experimental, investigational, cosmetic, an off-label use of a medication or is listed as a non-covered benefit by the health plan. Many of the common services or treatments for symptoms of ASDs fall into this category since research for child behavioral health and research for autism treatments has been underfunded for many years. There just aren’t a lot of outcome studies yet! </li></ul>Sue Lerner, Ph.D. 10/09
    16. 16. <ul><li>Consider a “mounting” a written appeal. Managed care organizations are required by law to have an appeal process. Appeal process details often accompany the EOB, are available on the company website and in their written plan materials. </li></ul><ul><li>Follow the details of the appeal process and pay attention to the time limits. </li></ul><ul><li>Several sources suggest that you can bolster the appeal of a Medical Necessity Denial by sending detailed documentation supporting why the treatment is necessary. </li></ul><ul><ul><li>If your doctor, therapist or service provider has not already submitted a letter detailing the recommendation and rationale, request this type of documentation. If the problem is long-standing or chronic, additional medical notes or assessment reports be helpful as well. It may help if your provider include copies of articles from established medical journals supporting the treatment. </li></ul></ul>Sue Lerner, Ph.D. 10/09
    17. 17. <ul><li>Health plans differ in appeal details. Sometimes appeals involve paper review only whereby the appeal is limited to a review of written medical notes during treatment. If treatment is ongoing, this type of appeal may impose great financial burden to the family because they will be responsible for the treatment costs. If the appeal is successful, the family will be re-imbursed for the covered expenses. The patient may request an expedited appeal whereby a phone consultation is arranged between the service provider and a health plan professional . This procedure is sometimes called a “doc-to-doc” appeal. </li></ul><ul><li>Some managed care companies offer voluntary external review appeals </li></ul><ul><li>If you have exhausted all appeals available through your private health insurance company, you have 30 days to request an external, independent review. These appeals are referred to the AZ Dept. of Insurance or to a medical reviewer approved by the Insurance Dept. See for details. </li></ul>Sue Lerner, Ph.D. 10/09
    18. 18. Sue Lerner, Ph.D. 10/09
    19. 19. <ul><li>Why should you participate in employer provided health services when your family member qualifies for public health insurance? </li></ul><ul><li>Economic “ups & downs” may undermine the security of some public services. </li></ul><ul><li>Uncertainty about health care reform. Some choice may be limited. </li></ul><ul><li>Broadest choice of best specialist providers. Best chance for a match between patient need and provider skills. </li></ul>Sue Lerner, Ph.D. 10/09
    20. 20. <ul><li>Your insurance company’s behavioral health “Level of Care Guidelines for Mental Health and Substance Abuse Treatment” manual. Usually a PDF file available online through your private insurance company’s website. This manual documents the criteria for your company’s continuum of care and levels of care. This is in addition to any manuals that you obtain each year when you renew your private insurance. </li></ul><ul><li> Consumer’s page of the AZ Dept. of Insurance. Consumer guides for various types of insurance as well as health care appeals. </li></ul><ul><li> Website is a project of Health Care for America Now (HCAN), grassroots campaign dedicated to winning quality, affordable health care we all can count on in 2009. The website has tutorials, an extensive health insurance glossary, and details and critiques each state’s health insurance rules. </li></ul>Sue Lerner, Ph.D. 10/09