Insurers Keep Saying “No” — But Patients and Clinicians Are Fighting Back

Denied claims and endless delays are pushing mental health and addiction care to a breaking point, but persistence and documentation can force insurers to approve life-saving treatment.

Discouragement from health insurer obstacles among patients, their families, and clinicians may be at epidemic levels. This is especially so for mental health and substance use disorder care, where an estimated 50% of mental health patients and 75% of substance use disorder patients do not have access to care. And an estimated 15 – 22 million mental health claims are denied by private insurers each year.

And insurance policy’s dispute resolution processes, typically only formal appeals, may be more discouraging than helpful. And laws and regulations requiring coverage of care seem impotent in the face of an insurer’s endless time and money to wait us out with delays and denials.

Fortunately, a new website, Cover My Mental Health, which was launched last year, can help level the playing field with its no-cost, immediately-actionable resources that support insurance coverage of care.

When the right medication faces insurance refusals

The medical necessity letter template from Cover My Mental Health is proving to be helpful overcoming an insurer’s medication denials, with significant less effort by the clinician.

At a Chicago-area co-occurring disorders clinic, an addiction medicine specialist faced multiple significant insurance challenges that were putting her patient in jeopardy. Delays in initiating treatment hindered her patient’s ability to reduce alcohol consumption and increased the risk of related health issues progressing to cirrhosis. The required treatment was clear: a long-acting injection for alcohol use disorder, but the insurer refused approval.

The clinician created a medical necessity letter based on the template, providing the reasonings for why a patient does not have to be fully abstinent, but just stable as the medication is used to support recovery. She said she included the clinical documentation along with the medical necessity letter and got approval from the insurer.

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Another clinician faced a comparable situation. A medication plan she had developed for a patient was refused by the patient’s insurer. Without a medical necessity letter in her toolkit, insurance approval often requires numerous, frustrating calls and weeks-long delays in care for her patient. As she described it:

“My teenage patient had faced a particularly challenging youth including hospitalizations to deal with acute symptoms that ultimately revealed a diagnosis of bipolar disorder. For this patient, the choice for stabilization, ongoing management, and the prospect for a high-functioning adulthood was clear. My patient needed a long-acting injectable. My clinical colleagues concurred. My patient’s insurer did not.”

“While my patient and her family suffered, my calls to the insurer to secure authorization led nowhere. Denials without explanation. Deaf ears to my assessment that failure to provide this medication would result in more hospitalizations. More denials. More avoidance of accountability for my patient’s well-being.”

“Weeks passed. Finally, on a weekend when I was out of the hospital, I got a call from yet another insurance company psychiatrist. This was the fifth such insurance company gatekeeper I’d dealt with.”

“I described the patient’s condition. Her medically necessary treatment. The avoidance of costly future hospitalizations. And, finally, a ‘yes’ that the medication was approved. No new information was presented. Simply my standing my ground and having someone get out of my way.”

“And now, well, my patient is thriving. No intervening hospitalizations. And no more insurance company fights… at least, not for her care.”

Absent a medical necessity letter to support that psychiatrist’s advocacy with the insurer, her patient’s care faced frustrating uncertainty and avoidable delays.

When denied out-patient care prevails with a medical necessity letter

Karen Pierce, M.D., a Chicago-based child and adolescent psychiatrist, was treating a teenage girl with mild obsessive-compulsive disorder whose symptoms became severe following an infection.

As Dr. Pierce previously shared with Psychiatric News,

“She was washing her hands raw and had to drop out of school. She didn’t want to go into a hospital but could do daily cognitive behavior therapy and exposure therapy. The insurance company said no to daily therapy, allowing only once a week.”

Pierce gathered evidence about the efficacy of exposure therapy, wrote a [medical necessity] letter to the insurance company, and was able to get the company to approve therapy three times a week. “This girl got better within six weeks, was able to go back to school, and eventually tapered the therapy to once a week. And she didn’t have to be hospitalized.”

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A woman with significant car-related anxiety was injured in a car accident but her insurance company offered payments only for her physical injuries. “I needed coverage for mental health services to deal with my anxiety post-accident, but I was not sure if mental health would be covered.

“Cover My Mental Health provided resources including a template letter of medical necessity that I could give to my mental health care team in order to get services covered. The letter detailed the reasons why mental health services were necessary following the accident and outlined a treatment plan. I sent the letter to my insurance company, and they reimbursed me for mental health services, no questions asked!”

Impatience is the mother of invention

Over the last seven years, I have worked with many others to advocate for better laws and enforced regulations for mental health care at both a federal and state level. While those efforts are important, it became clear that patients and their providers needed resources like Cover My Mental Health today.

In the words of Eric Plakun, M.D., long-time advocate for access to mental health care, former Medical Director and CEO of Austen Riggs Center, and now board member of Cover My Mental Health, “A lot of us in advocacy are working to shape future policy and legislation, but Cover My Mental Health now helps patients and families immediately, using available tools to secure access to care now.”

Joe Feldman is president and founder of Cover My Mental Health, a non-profit supporting patients, families, and clinicians to overcome insurance obstacles to care. Feldman previously served as a board member of Kennedy Forum Illinois and currently serves as a Consumer Representative to the National Association of Insurance Commissioners.