Dear friends,

The most frequently asked questions to the Anna Westin Foundation involve barriers to insurance coverage for eating disorders. While we do not have the answers we have several suggestions that may be helpful.

History

When our daughter Anna was struggling with anorexia and needed intensive, specialized care our insurance company told us repeatedly that her treatment was not necessary or that what her doctors were recommending was not what they would pay for. This was outrageous and we had trouble believing what we were hearing. As most of you will understand, we had little time or energy to fight those decisions at the time but intended to fight at a later date when Anna was no longer in crisis. Tragically, Anna died from anorexia on February 17, 2000. We made a decision as a family very soon after her death to do what we could to fight eating disorders which included addressing the problem of limited access to care.

As we began exploring this issue we learned that most insurance companies deny or severely limit care for eating disorders and most mental health diagnoses. They have policies and practices in place that discriminate against people with mental health issues and have been doing this for years. We researched who could help us address this issue and we decided to contact MN Senator Paul Wellstone (who worked hard to pass National Mental Health Parity Laws) and Minnesota Attorney General Mike Hatch and asked for help. Both men responded immediately and agreed to do what he could to address the huge crisis of access to care for people struggling with mental heath problems.

Attorney General Hatch filed a lawsuit against Blue Cross and Blue Shield of Minnesota in October of 2000 for their illegal pattern and practice of misconduct in denying, delaying and withholding necessary mental health, chemical dependency and eating disorder treatment for Minnesota children and young adults. The suit was settled out of court in June 2001 and we are pleased with the settlement. The result has been greatly improved access to care for people in Minnesota who have BCBS insurance and a surprising (but hopeful) result has been that several other insurance companies have voluntarily agreed to the provisions of the settlement. To read the complaint and the settlement please go to our website at; www.annawestinfoundation.org.

We believe that denying access to care for eating disorders is illegal and immoral. The policy of denying treatment for mental disorders must come to an end. We need to educate insurance companies and if necessary force them to authorize life saving care for people who suffer from eating disorders. We understand how frustrating it is when you have a very sick family member and your insurance company questions the need for treatment. We have created what we hope will be a guide that will help you through the appeals process. Remember that what you are asking for is reasonable and that you have been paying for insurance so you and your family would be covered in case of a life threatening illness. It is also helpful to keep in mind that insurance companies are not the enemy but they are generally uneducated about eating disorders. Your job is to educate them so they understand the necessity of the requested treatment. It is always easier to get your insurance company to work with you if you approach them in a non-threatening manner. Try to leave your emotions out of it and always be civil, polite and determined (not aggressive). I often suggest that people write two letters. The first is full of emotion and states what you really think and feel. You “let it all out” in this letter than tear it up and begin the second letter. The second is polite and respectful but it does convey your determination and unwillingness to give up until you get your loved one the care she/he needs.

What to Do

One of your first steps is educate yourself. Read your insurance manual and determine what mental health benefits you have. If you have difficulty understanding the document call the Customer Service number on the back of your insurance card. You must have accurate information as you move forward.

It is also important to understand which covered treatments are funded through the “health” section of your plan and which are funded through “mental health” section. For example, your psychiatrist and medical doctor will be funded through “health benefits” and you should insist that these are billed this way. You will probably have lower co-pays and services will not be as limited.

At this time it would also be helpful to determine if your state has a Mental Health Parity Law. Mental Health Parity states that insurance companies must not limit mental health care by imposing lower day and visit limits, higher co-pays and deductibles and lower annual and lifetime spending caps. Go to the National Mental Health Associations website (www.nmha.org/state/parity) and click on; “What have states done to ensure Health Insurance Parity” for a complete list of which states have parity.

It is important that you understand the “rules”. You cannot play the game without all of the rules and generally the insurance company has access to the rules and you don’t. Call your insurance company and ask them to explain such things as the appeals process, what criteria they use to determine medical necessity and who makes these decisions. In Minnesota we found that it was standard practice to hide from subscribers the true conditions, standards, and criteria for denials of coverage which places the subscriber at an unfair disadvantage during the appeals process. Request a copy of the written criteria and also the names and positions of the people making the decisions. It is also important to find out who the President/CEO of the company is and send copies of all letters to him or her. Remember to carefully document every phone call including the name of the person you spoke to, date and time, and what was said or decided. Exhaust the appeals process and be very careful when you submit forms; we found that long delays were often caused by insignificant omissions or mistakes such as leaving out a requested number.

As you begin the appeals process we suggest you get a copy of the APA (American Psychological Association) Guidelines for treating eating disorders. You can find these at: http://www.psych.org/psych_pract/treat/pg/eating_revisebook_3.cfm#pgfld_1077368.
Send a copy of these to the insurance company along with the other information and request that your loved one’s level of care be based on the accepted guidelines. If the request is denied or your insurance company states they use a different set of guidelines insist that they take full responsibility for your child’s life noting that they are disagreeing with the qualified experts in the field and the approved guidelines.

There will be times when you can solve the problem quickly and relatively easily. After you receive the first letter stating that the requested treatment was denied we suggest you call the company and ask to speak directly to the Medical Director. The person answering the phone typically cannot reverse the decision so you need to speak to someone who can. Ask the Medical Director for a detailed explanation of why the request was denied and what criteria was used to determine this. Try to “join” with him or her by stating that you believe an error was made and that it needs to be reversed. Have your documents at your side so you can explain clearly and effectively why you are right. Again, it is very important that you document everything that is talked about.

If the simple attempt does not work you will need to file an appeal. As stated before, be sure you understand what the company’s appeal process is and follow it completely. Once you have the information you need from the insurance company start putting together a packet to send to the review committee and the president of the insurance company. Write a letter that is brief, clear and states your expectations and goals. (see sample letter) Present your concerns clearly, concisely and in understandable terms. Briefly tell your story and state your expectations. We also think it is important to ask for a response within a defined time period.

In the packet you will also include documentation, evidence and facts. Ask your treatment team for documentation supporting your request and the rational for the treatment recommended. Very often insurance companies deny or limit coverage after mere “paper reviews”, contradicting the judgment and recommendations of the professionals who have examined and treated you or your family member. It may also be helpful to include research and other scientific evidence. To find appropriate information ask your doctor, psychologist or other professional or look at the Academy for Eating Disorders website; www.aedweb.org. The AED is the professional organization and publishes the latest research findings. Or, go to; www.nationaleatingdisorders.org and see “Ammunition for Arguments with Third Parties: by Dr. Margo Maine for information to back-up your argument. We think it can also be useful to include information about the lawsuit in Minnesota and the private settlement our family reached with our insurance company for the “Wrongful Death” of Anna. Please feel free to use any and all information on our website at: www.annawestinfoundation.org. You may also decide to include a photo of your loved one if she/he is significantly underweight.

Send all of the information to the insurance company and be sure to copy it to the president of the company, your states Attorney General, Insurance Commissioner, US and State Congress members, advocacy organizations, your attorney and anyone else you think might be interested. If you have an insurance agent or a human relations representative at your company copy the material to him or her and ask for assistance.

One last piece of advice, “DON’T GIVE UP”. Most insurance companies count on people accepting the denial and not following through with the appeals process. We recently heard that when people follow the entire process they win in 75% of the cases.

We are sorry that you are in this position and we wish there were easier answers but we trust that over time and with thousands of people like us fighting we will change the system. If you are interested in joining the national advocacy movement working to end discrimination against people with eating disorders go the Eating Disorders Coalition for Research, Policy & Action website: www.eatingdisorderscoalition.org. The Anna Westin Foundation is a founding member of the group and we believe that the work we do in Washington will have a nationwide impact. We are currently working on a number of bills that will directly address the issues talked about in this letter.

We wish you the best.

With warm regards,

Kitty and Mark Westin
The Anna Westin Foundation

(For additional information and resources go to the National Eating Disorders Association website: www.nationaleatingdisoders.org.)