How to Navigate Insurance Coverage

By Cyndi Eddington


Cyndi Eddington:
Hi, I'm Cyndi Eddington. I'm the Chief Business Services Officer here at Eating Recovery Center. Welcome to my Family Days presentation. What my title means is, is that I'm in charge of insurance contracting and managing claims with my colleagues in the business office. Our goal is to make sure that your insurance, the policy that you have supports as much time here at the recovery center as possible. I know this is what it feels like when you have a loved one in care in a psychiatric hospital, needing assistance, you don't know what is left, what is right, which way to turn. I really want you to see the business office as a resource to you in terms of understanding your insurance. Before I go any further, I'd like to tell you a little bit about me. So I used to think that I did the work that I do, working with insurance companies, working with insurance contracting, because that was the opportunity that was presented to me.

But over the years, I know it's different. I know that I was given this information so that I could help my children. The story is in 2012, four years after I started working for Eating Recovery Center, I had a daughter who came to me in her first year of college and let me know that she was struggling with bingeing and purging. I then later find out, but things were much more serious than I anticipated, after we sent her home from Christmas break. And bills began to come in from emergency rooms up near the university. So we stopped going to school that summer. And we started focusing on getting well. And I'm happy to say, now that my daughter is doing better. And I'm so grateful that I knew what I know, so that I could navigate the financial questions while my daughter was in care. I've also had other experiences in my life with my kids, where I really needed to understand mental health and insurance.

And so my goal is to pay it forward. The reason I'm on the phone with insurance companies, the reason we work through these partnerships is to support you. And it's my pleasure to share some of this information with you today. I want you to understand how the business office is organized, so that we can provide the services to you that you need. The first individual that you will probably talk to is the Patient Admission Coordinator. This is the individual that has been trained to understand insurance benefits, very specific to mental health care. And it is not unusual for them to call back three or four times, to understand what your benefits it might be. These individuals then will contact you if you were listed as the financially responsible party, or that we can speak with you on behalf of your loved one. And we will translate that information to you, and help you understand how your policy will support care for your loved one at Eating Recovery Center.

Next we have the Patient Registration Team. Everyone in the business office is a Patient Registration Team member. And the reason for that is first off, we need to come and get your insurance card, and a copy of your driver's license, and make sure we've got the numbers right, so that your claims can get paid. But mostly we want to meet you. We want to meet who you've brought with you. We want to answer your questions in case there's something we missed before. And we want to be sure that we're here to support you, and provide you with information on how to get ahold of us.

The Medical Billing Specialists team is a team that you will probably never speak with. But what they do is gather data that translates to codes, that are delivered to the insurance company in order to have your insurance policy reimburse on your account, according to what they promised us, when the Patient Admission Coordinators were talking with them. Patient Financial Counselors are the individuals that once you admit into treatment and if you are listed as the financially responsible party, they are available to answer your questions at any time. They will work with you and work and look at your account until everything has been resolved.

What I always say now is, no news is good news from the business office. If we never reach out to you, it means that everything is going well. But know that when we reach out to you, we're here to give you information, and guidance, and support you at a very difficult time.

The Patient Account Coordinators, lastly, are they individuals who speak with the insurance companies every single day about every denial that comes into the system. So if your loved one is in inpatient care and we've been authorized to provide that care, and the policy supports that, then we expect your third party payer to pay for that claim. And when they denied, this is the team that's going to be on the phone with them and asking them why. What I want you to know is you can really partner with us in this. Your voice is so much louder than ours. If you receive anything, where you feel that your payer is not supporting what you've expected, know that you should contact them as well as contact us. Sometimes something that can be really effective is having a conference call with a claim specialist, you as the insured policy holder, and the insurance on the other side of the line. So we can all get to the same page.

I know when you come, and you talk to the Patient Admission Coordinator and they explain your benefits to you that often what we hear is that we're going to pay our deductible this year, then our insurance is going to pay 80% and we own 20% up to say another $2,000. And then everything should be covered because you've paid your out of pocket max. What we know to be true is sometimes there are items that get in the way of that conversation. And so what I want you to understand is how a policy that can be incredibly supportive on the front side, where we may come into speed, bumps and problems say several weeks into treatment. So these are issues that can impact you.

First started your benefits. Some policies do not provide residential care, and some policies may have other limitations due to being a grandfathered status, or part of a not-for-profit organization, or a federal policy. Know that those are limitations that are baked into your policy that you have. We can't have a lot of influence on that. Although occasionally we will find a payer that we feel is mandated to have these benefits available, and doesn't, and we will certainly engage with you and tell you what we know at that time, to see if we should challenge that further.

Medical necessity guidelines. Medical necessity guidelines, if you were to go to say your insurance website and type in medical necessity guidelines for eating disorders, you would likely come up with the list that the insurance company uses to decide whether or not your loved one needs the care that we're asking for, and whether or not they can continue in the level of care that they're in. And also it helps to make decisions for the payer in terms of times to step down to a lower level of care. What's important for you to know, is that there are the APA American Psychiatric Association guidelines, which are the gold standard for eating disorder care.

And while the third party payers utilize those guidelines, they are able to adjust them. So know that these medical necessity guidelines are different for every payer that we work with. And that is why patient A may have a different length of stay than another patient that might be say, with your daughter and Karen, you don't understand why your daughter isn't receiving additional support from their insurance. This is something that really can make difference across lines for the patients, and for you as a family member. So we want you to understand that this is something that is guiding care, from your third party reimbursement perspective. What is concurrent review? This is something that I hear all the time from families, and it's really important to understand. 98% of the patients who admit to Eating Recovery Center have a managed care organization that works with their third party payer.

This managed care organization requires that our utilization review team, which are licensed clinicians, speak with their case management team at the insurance on a regular basis. You might wonder what I mean by a regular basis. It can be every two to three days. The most I've ever seen go without us talking to a payer, is maybe 10 days. What you need to know as a family member, is that lots of letters are going to be coming to you because of this concurrent review process. And those can really create a lot of anxiety for you, but it is a normal part of our day here at Eating Recovery Center. And even though you may have no day limitations on your policy, you are still subject to concurrent review, which means that your managed care organization is consistently looking and speaking with us, to decide if your loved one meets medical necessity guidelines and can continue in care in terms of reimbursement by the carrier.

During concurrent review, when we provide this data, the clinical data about your loved one to the insurance company, they have a few different choices. They compare the information to the guidelines and the case manager is either going to say, "You're asking for an additional seven days, in partial level of care. We completely see that Jane meets that criteria. And we're going to go ahead and authorize another four days, please plan on calling us back on Thursday," or we might contact them, ask for the additional seven days. And the reviewer is going to say, "I'm sorry. I don't believe that Jane meets the criteria for continued stay in the partial level of care according to our medical necessity guidelines, I cannot authorize additional time." The first step that we're going to do is we're going to ask for a peer to peer review. A peer to peer review means that your loved one's attending psychiatrist, or psychologist, will speak with the provider's psychiatrist, to talk about the case further.

And we're hoping that we can provide this information. And when peer physician speaks to another peer physician, that perhaps we can get additional time authorized, and we may indeed get time authorized. Often, we'll hear that there's another three to four days authorized. And then we go back into the concurrent review process. However, if the physician says no, we typically, we only have one more opportunity to advocate for you. That is known as an expedited appeal, an expedited appeal takes approximately 72 hours to complete. And so that is a time when you are not guaranteed that the services they're being delivered to your loved one are going to be reimbursed by your insurance company, as you originally thought.

So what I always say is, as soon as we know, you'll know. We understand that the concurrent review process has hit a bump in the road due to medical necessity guidelines, you'll be hearing from us. The business office, the Patient Financial Counselor assigned to you will reach out to you. They will help you to understand where things are, what is happening and what does this mean to you financially.

If your insurance does not continue to authorize care after the expedited review, you do have appeal rights, and those appeal rights are available to you in your insurance policy, as well as if you receive a denial, the denial at the end of the letter, please watch in the mail for this, will talk about all of your options beyond the expedited appeal as the insured policy holder. I encourage everyone to follow their due diligence, but it does mean if the insurance is not supporting care here, that we will be looking to understand what amount of time could you continue based on the clinical recommendations from the treating team for your loved one. And that will be a conversation that we will have at that time, so that you can make a decision. You'll also be talking closely with your clinical team to understand their recommendations and to understand what your loved one is still needing to accomplish in treatment.

Over the last couple of years, there's been a lot about affordable care and federal parody. I've learned that often, especially if your loved one is young, that you really don't understand the language of parody. And we speak about it here so often that sometimes we forget. So what's important to know historically, is that not so many years ago, mental health was discriminated against by insurance companies. So if you had diabetes, and you needed to see the doctor 10 times this year to manage your diabetes, of course you would get the care that you needed. But if you had a mental illness, you had 10 days a year to get better. Most of that is gone now. Thank goodness we know that insurances must now provide care, and managed care that is equal to the medical benefit. In other words, because you're mentally ill, you don't get less care than someone who is medically ill.

That legislation has come through Accountable Care, but even before Accountable Care. And I always want to acknowledge families at this time, because it's really been on the backs of families who have struggled, who have had bad experiences, who have gone to their state legislatures, and made a difference in what we see today in mental healthcare. So our experience so far is that Accountable Care has been a good thing. It's been a good thing because, if you have a young adult, you can keep them on your insurance policy until they are age 26. That has made a huge difference for families who are needing a young adult to get into care. Often we as parents will have large group policies and policies that are quite robust to support the care.

Also, you can no longer be denied care due to preexisting conditions. When I first started working at Eating Recovery Center, there were many individuals who were not eligible for care because they had struggled with their eating disorder before they were insured. That is no longer the case due to the legislation. In addition, they must cover essential health benefits. And because of the marketplace, you can go out and buy an individual policy that has essential health benefits, and therefore brings to the table, all of the legislation in terms of parody to your loved one. These are important websites that you are welcome to go and look at and research further. If you have additional questions about federal and mental health parody and how it impacts you.

What I really want you to know is here at Eating Recovery Center, I am really proud and committed to having insurance contracts with every major insurance across the country. We want to deliver our expert care to every single individual that we can. And we know that insurance contracts help to create access to care. So we've focused on that partnership, even though we know sometimes we agree to disagree. What I know, is for every payer that we're contracted with, that gives you as a financially responsible party or family member, an opportunity to have your payer pay for the care. And for every single day that they cover, that's a day that you don't need to worry about.

I hope that you've gotten what you need from this presentation. And that you understand better how we work with insurance companies here at Eating Recovery Center. And perhaps there's just a little bit less confusion. And I want you to know that if any questions come up or you need anything further, please contact the business office at Eating Recovery Center. Thank you.

Eating Recovery Center is accredited through the Joint Commission. This organization seeks to enhance the lives of the persons served in healthcare settings through a consultative accreditation process emphasizing quality, value and optimal outcomes of services.

Organizations that earn the Gold Seal of Approval™ have met or exceeded The Joint Commission’s rigorous performance standards to obtain this distinctive and internationally recognized accreditation. Learn more about this accreditation here.

Joint Commission Seal