scheduling a routine checkup or have a medical emergency, your health insurer should significantly reduce the cost of treatment. So what should you do, then, if you need dual diagnosis medical care and your health insurer denies your claim?
Insurance companies do not only operate solely to pay your claim, they also have to make a profit. Unfortunately, some insurers may resort to bad faith practices like wrongful claim denials or unreasonable delays. There are several reasons that could lead to the denial of your health insurance claim. Some of these include:
- Your insurer believes that the treatment you received was not medically necessary
- Claiming that your dual diagnosis coverage is not provided in their policy
- Denial or delay in authorizing treatments such as specialist care or MRIs
- Your insurer claims that the procedure you underwent was too experimental or investigational
- Declaring pre-existing conditions
Without taking immediate legal action, you could be slammed with the full brunt of your medical bills that could range into the thousands. However, trying to call out a health insurer for wrongfully denying your claim will most certainly see you go up against a corporate giant and its full legal resources. Therefore, you need the legal services of a seasoned law firm like Stop Health Insurance Denial to help you rebalance the scales back in your favor.
Our seasoned attorneys understand what is at stake in a case against an insurance company and will, therefore, fight tenaciously to secure you the best result possible. We assertively represent the sick and disabled all over the U.S. We take on clients whose claims were declined under non-ERISA (which represents the individually purchased) health policies as well as ERISA (representing the employer-sponsored) benefit plans. If you are wrongfully denied your health insurance claim, do not take the decision as final. There are strong legal options to pursue to appeal the denial, which is why a seasoned attorney is essential.
What is Dual Diagnosis?
The concept of dual diagnosis emerged in the 1990s but is still not well understood even by the medical establishment despite it being quite simple and effective. It describes a practice that emerged to treat people suffering from both a psychiatric disorder and an addiction.
You can be addicted to alcohol, drugs, gambling, sex, or a combination of things, and you can also have a psychiatric disorder such as bipolar disorder, schizophrenia, depression, panic disorder, eating disorder, borderline personality disorder, dissociative identity disorder among others.
According to the concept of dual diagnosis, a high functioning alcoholic can also suffer from mood disorders; a bulimic can be bipolar; and a crack addict can have clinical depression. Due to this dual nature of affliction of many addicts, a majority of them remain largely undiagnosed and untreated. This results in a sky-high incidence of relapse.
The US health care system is designed to work in one of two possible ways:
- Sequentially: First, the addiction is addressed before the underlying psychiatric problem that drove you or your loved one to seek solace in drugs, sex, or alcohol. Sadly, there is usually a time lapse between the two treatment phases that results in relapses.
- Separately: Here, the emotional problem and the addiction are treated by different doctors at the same time. This results in neither of the doctors having a comprehensive picture of your health. Also, each doctor becomes tentative with your prescription medications for fear of exacerbating the other condition.
The health industry is rising up to the fact that dual diagnosis is the key to a true recovery since addiction, in its essence, has little to do with addiction. It has everything to do with anxiety, depression, trauma, biochemical imbalances in your body, and your attempt to relieve or regulate your level of pain or discomfort.
As such, your recovery is largely dependent on receiving the best possible health care, which requires your health insurer to pay for your medical bills. Unfortunately, many insurance companies use loopholes in their policies such as pre-existing conditions or unnecessary medical procedure clauses to stonewall patients and deny their claims.
Does Your Health Insurance Cover Dual Diagnosis Health Treatment?
All marketplace plans must cover substance abuse and mental health services as essential health benefits. The cover includes:
- Behavioral and mental health inpatient services
- Behavioral health treatment that includes counseling and psychotherapy
- Substance use disorder treatment also commonly referred to as substance abuse
The specific behavioral health benefits you receive are dependent on your present state and the health plan you chose. If your health insurance plan was purchased through state exchanges that are set up by the Affordable Care Act, then mental health care is covered. Also, if you have insurance through an employer, chances are that you are also covered.
Pre-existing behavioral and mental health conditions are also covered while spending limits are not allowed. This means that:
- Marketplace plans are not allowed to charge you more or deny you coverage because you have a pre-existing condition that includes substance use and mental health disorder conditions. But you must disclose any knowledge of such conditions when taking out a health cover.
- The coverage for treatment of any pre-existing conditions starts the day that your cover takes effect.
- Marketplace plans are not allowed to put a lifetime or annual dollar limits on coverage of any health benefit considered essential, which includes substance use and mental health disorder services.
Parity Protection Laws
Marketplace plans are required to provide parity protections between mental health benefits and substance abuse benefits on the other. This essentially means that any limits applied to substance abuse and mental health services cannot be more restrictive than those applied to surgical and medical services. Limits covered under parity protections include:
- Treatment: Such as limits to the number of visits or days covered.
- Financial: Such as Deductibles, co-insurance, co-payment, and out-of-pocket limits.
- Care Management: Such as the requirement to get treatment authorization before getting it.
Does Insurance Cover Rehab?
The realistic answer to the above question is: ‘It depends.’ The majority of substance abusers fail to go to rehabilitation centers for treatment due to either a complete lack of health insurance coverage or insufficient insurance coverage. This means that many of the substance abusers who urgently need treatment do not receive it while those that do mostly pay out of pocket.
The inception of the Affordable Care Act changed the face of insurance coverage across the country. The national health care plan was drawn up, in part, due to the longstanding concerns about the poor health insurance coverage that many Americans suffered.
At the time of its implementation, about 45.2 million Americans below the age of 65 were uninsured. Out of these, 61 percent had private insurance. Under the Affordable Care Act, anybody who was previously not insured was covered by the act. One can also apply for public health insurance under state Medicaid benefits. Alternative sources of coverage are employment-based insurance covers and dependent benefits (where coverage is provided through a parent or spouse employee).
If you have a dual diagnosis or are a substance abuser, you should do your due diligence before signing up for health insurance to ensure that your medical condition is covered. If your substance abuse has progressed into a state where self-help is impossible, a loved one may step up and contact potential private insurance carriers and health care navigators on your behalf to help you get the best cover possible.
What to Do When Your Insurer Denies Your Dual Diagnosis Coverage
The treatment of substance abuse and mental illness may be denied by your health insurer for a number of reasons that stem from a variety of methods used to determine whether a treatment is considered part of your benefits or medically necessary.
If your cover entitles you to a dual diagnosis treatment support or service, you have the right to appeal a denial decision. You should consult a lawyer if you feel that your insurance company has acted in bad faith by denying your claim since there are state and federal laws in place to protect you.
Getting denied for a needed dual diagnosis care service can be frustrating. This is partly because of the confusing terms used by insurance companies to stonewall or intimidate you. Some of the terms include:
- Medical Necessity Criteria: These refer to standards used by insurers to decide whether health care supplies or treatment plans recommended by your health provider are appropriate, reasonable, and necessary. If your health plan is satisfied that these criteria are met by your treatment, then they will consider your requested care as a medical necessity and accept your claim.
- Utilization Review/Utilization Management: This is a process used by insurance companies to decide whether the requested dual diagnosis care is efficient, medically necessary, and in tandem with accepted medical practice.
- Prior Authorization: This term is also referred to as pre-authorization, prior approval, pre-approval, or pre-certification. This is a utilization review that requires you, or your health service provider, to ask for approval from your health insurer before they pay for a treatment plan, service, or prescription drug.
- Step Therapy: This prior authorization requires you to try a less expensive service or prescription medication before moving on to a more expensive treatment course.
You should appeal your claim denial if you think that you need the requested health service based on your benefits and care needs. You may also appeal a denial if the requested treatment for your dual diagnosis condition is not considered equal to other surgical or medical conditions. This appeal will be on the basis of mental health parity laws that are protected by both state and federal laws.
Some of the signs that you have enough grounds to file an appeal (under parity law) following a claim denial include the following:
- Fewer visits and higher costs for mental health services compared to other types of health care.
- The requirement to seek permission to get dual diagnosis health care, but not for other kinds of health care.
- Getting denied dual diagnosis health services on the basis of medical necessity, but the insurer fails to provide the criteria it used to determine such necessity.
- Your health plan refuses to cover intensive outpatient care or residential dual diagnosis treatment, but does so for other health conditions.
- Inability to find in-network dual diagnosis health providers looking for new patients, but you can find available providers for your other health care needs.
Some of the most commonly denied types of health care include:
- Residential treatment for mental or dual diagnosis conditions.
- Intermediate care such as psychological rehabilitation, intensive outpatient treatment, drug use disorder treatment, assertive community treatment (ACT) or partial hospitalization.
- Office based diagnostic interventions and treatment options that include diagnostic assessments, psychotherapy, or standardized tests such as the PHQ-9 (Patient Health Questionnaire 9) that measures depression.
Steps to Take If Your Claim is Denied
Your insurance company has an obligation to inform you why your claim was denied in terms that you understand. Typically, your insurance company sends you a letter outlining your explanation of benefits (EOB). Any questions that you have should then be fully addressed by your insurer.
- Check for Clerical Errors
Sometimes claims may be denied because of clerical errors such as wrong ID number, address, or service date. Such mistakes can be easily corrected.
- Compile Evidence
If the denial was not due to a clerical error, you need to compile all the evidence in your favor detailing why the services received (or requested) were medically necessary and within your coverage spectrum. Such evidence includes all relevant information regarding your medical history, prescriptions, and treatments. You need to collect your medical records from your health provider or authorize them to disclose the records to your insurer.
- Challenge the Claim in Writing
Send your insurer a letter and your standard appeals form to start the internal appeal process. Include your insurance ID, claim number, and convey your issue as well as a proposed resolution. Be polite and professional but assertive.
- Beware of Time
Your right to appeal a claim denial is finite and varies based on the coverage provider of your choice and the type of claim. It is best to initiate the appeal process as soon as possible.
- Hire an Attorney
If you go through the internal review process and your claim is still denied, then you are free to seek an external review in a law court. At this point, you will need the services of a seasoned attorney.
Why Hire Stop Health Insurance Denial?
Stop Health Insurance Denial is a leading law firm that operates nationwide and concentrates on insurance denial and bad faith cases. When you (the policyholder) have your claim denied or cannot get the coverage that you need, you can rest assured that when you bring your case to us, we will get you results. We take on all cases, force insurance companies to change how they respond to claims and cause others to change the types of health conditions they cover.
The truth is that many people do not think they can get any recourse after their insurance claim is denied. This more so applies to dual diagnosis patients since even the medical establishment does not fully understand this medical concept.
The situation is compounded by the fact that insurance companies always seem to have entire libraries of documentation behind the decisions they make concerning whether or not a treatment is covered under their policy. Unfortunately, dual diagnosis patients always get the short end of the stick in such situations because of their addiction.
While these cases can be hard, you need not be intimidated by your insurer and their tons of paperwork. Stop Health Insurance denial has the resources and expertise to take on any insurance giant. The truth is that when an insurer denies treatment based on its interpretation of policy, this decision can affect countless other dual diagnosis patients in the same situation.
Insurance companies deal with claims on a daily basis; therefore, they know all the loopholes in their policies and how to utilize them to their advantage. Despite their marketing pitch, health insurance companies remain loyal to their shareholders, which means that every claim they deny payment results in a higher profit margin and more money in their shareholders’ pockets. You need a dedicated attorney on your side who is not only backed by a resourceful law firm but also has the depth of experience and skill to take on any insurance company irrespective of their size.
The bottom line is very simple. The role of your physician is to provide you with proper medical treatment that is in your best interest. The role of your health insurer is to help you pay for medical care as promised. The role of a Stop Health Insurance Denial attorney is to ensure that you get the best care you need under the insurance coverage you paid for.
Finding a Dual Diagnosis Denial Attorney Near Me
If you are facing unfair treatment from your insurance company and are looking for a dual diagnosis denial attorney call Stop Health Insurance Denial at 310-695-5241 to schedule an appointment or a free consult. We operate nationwide and can handle cases right over the phone, but you can also feel free to visit our local office with a scheduled appointment.