Obtaining payment for appropriate health care can be difficult and complicated. Insurance policies often have annual and lifetime limits on payment for health care. One option is to ask the individual company if, for example, payment for refeeding for anorexia on a medical floor is considered a "medical benefit" rather than a "mental-health benefit."
It is not unusual for utilization reviewers to issue what they call a "denial" - in essence, they do not authorize payment for care. If your treatment provider believes that the case is "appropriate" and they can "justify" (utilization-review terms) to the insurance company that the case meets the company's medical-necessity criteria, the denial may be overturned. Interestingly, some states publish the percentages of denials overturned on appeal for each insurance company that does business in their state. Also, there are several levels of appeal within each company, and most states have an insurance commission that will do a final appeal review.
Find out if you are eligible for Medicaid or Medicare and whether the treatment program you're interested in accepts those forms of payment. To find help with insurance issues, parents should go to their employer's human-resources department, the business office of the treatment program you are interested in, or your state insurance commission.
Often a private health insurer or Medicaid will identify someone, frequently a nurse-practitioner, to coordinate or "manage" the care provided. It is very important to know who that person is and to communicate with her directly. Care managers also may be used to track whether a patient is moving through levels of care. Finally, you can turn to your local social-service agency, where a caseworker or advocate can help unravel the rules.
When choosing a treatment program, ask specific questions to find out if the program uses practices supported by research. Find out if the program follows the latest scientific knowledge, uses credentialed mental-health and eating disorder treatment professionals, and prescribes medication, when necessary, to assist in the recovery process. If the program follows evidence-based practices, you will have a better chance of having effective care and improved chances for recovery. NEDA provides this summary of what treatment is recommended for which severity of diagnosis. Patients who can show that these treatments are needed and provided may persuade insurance companies to pay for them.
Inpatient hospital treatment is called for when a patient is "medically unstable", that is, with unstable or abnormal vital signs, when lab results show acute risk, or when coexisting medical problems such as diabetes present dangerous complications. They also recommend inpatient treatment when someone is psychiatrically unstable, whether he is suicidal and personally unsafe, or his mental symptoms are rapidly worsening.
Residential treatment - that is, in a nonhospital but live-in facility - is considered appropriate when a patient is medically stable but may be unable to maintain safety without 24-hour supervision to decrease the risk of relapse, and is not considered safe to be at a day treatment facility where he goes home at night.
Many people with eating disorders can benefit from "partial hospital" or day medical treatment. This is appropriate when medical professionals determine that patients are medically stable, that is, their eating disorder may impair functioning without causing immediate acute risk, but they need daily assessment of physiological and mental status. The least intensive level of care takes place in an outpatient setting. The patients are medically and psychiatrically stable, with symptoms in sufficient control to be able to function in normal social, educational, or vocational situations. Ideally, a person with an eating disorder should be able to get exactly the level of medical care he or she needs, but often people need to piece together the care they can afford.
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