I have included this page on how to deal with the appeals process under the treatment section of the table of contents because I believe that assertively appealing an insurance company's denial of treatment can be an important part of therapy, for both client and therapist. Standing up for oneself and refusing to allow "authority figures" deny one one's rights can be a strengthening experience. Unfortunately, whether or not the client and therapist fight back, this whole process tends to be retraumatizing. That, of course, is the exact reason it is usually best to fight back.
I use the words "fight back" advisedly because, have no doubt about it, most appeals of negative insurance decisions quickly degenerate into adversarial interactions. Let's face it, the authoritarian types who willy-nilly make these life-and-death decisions based on financial considerations over-and-above human needs do not like to be questionned, let alone contradicted. This may not always be the case. But if not, I have yet to hear any evidence to the contrary. Indeed, if anyone out there has had any positive experiences in this regard, please let me know, and I will share it with the everyone else. Meanwhile, my experience tells me that anyone who enters into the appeals process can not hope for much humane treatment from those operating on the insurance company side.
I can only speak from my own personal experience dealing with one of the worst companies in the United States, MCC Behavioral in Massachusetts. (As you can see, I believe in naming names. Anonymity for despicable behavior is counterproductive in my book.) This insurance company has a history of preying on volunerable people. They have admitted as much to Mike Wallace on 60 Minutes. The American Psychiatric Association has denounced their practices. They have been sued successfully for millions of dollars in Massachusetts alone. The last I heard they were being sued by several psychologists in New Jersey whom they had dropped from their providers list because these psychologists had the temerity to question the companies idiotic treatment guidelines (see below).
As you can see, I feel passionately about this issue.
So, rule number one when an insurance company decides not to allow treatment for a client: appeal (that is, fight back).
Rule number two, get a copy of the company's treatment guidelines. As a therapist you have a right to this. Indeed, you should get copies of the guidelines from all of the companies you deal with before any problems come up. It could save you some time later on. Once you get the treatment guidelines, go over the guidelines that relate to your client's problem(s) with a fine-toothed comb. More likely than not they will make very little sense. MCC Behavioral, for instance, required a 50% reduction in symptoms within 6 weeks of treatment.
Rule number three, write out in detail the ways in which you believe the literature does not agree with the guidelines. You will not want to start by questioning these guidelines, but somewhere along the way you are likely to do just this. I, for example, asked them on what basis they based these guidelines. Why did they expect to get 50% reduction of symptoms in 6 weeks. Indeed, how were they proposing to quantify symptoms? They had no answer, of course.
Rule number four, try to get things in writing. A paper trail is a vital part of the appeals process. If you do have telephone conversations, take notes on what was said during the conversation immediately upon getting off the phone. Be sure to include the date and time of the call and the name of the person(s) with whom you spoke. Try to make verbatim quotes as much as possible. Then, somewhere during your written transactions with these people, be sure to include a copy of this transcript of the conversation. That way you have entered it into the record.
The main reason to get things in writing is that this contributes to your evidence of the interactions you have had with the insurance company. This evidence could very well come in handy somewhere along the appeals process. It also helps to remind some of these people of things they have told you in the past.
If my experience is any indication, there are several levels for you to go through in the appeals process. First, the therapist should appeal the insurance company's decision. Do so in writing as well as by phone. In your letter, summarize not only why you believe the client needed to see you in the first place, but, if they have been seeing you for a while, indicate the progress they have made so far, and then be sure to indicate how much progress you believe they still need to make. This proved to be cruicial in my own case. The therapist involved did just this early in the process. Later the idiot who was in charge of denying the claim made the stupid mistake of claiming, in writing, that the therapist did not believe the client needed any more treatment. Bingo. We had this person. This is evidence of negligent treatment which, in this case, could be said to have led to a worsening of the client's medical condition. In other words, we could have sued. And we let the people who had the final say know that we knew we could sue. That was all it took -- eventually (read on).
Usually when the therapist and/or client is advised that their treatment request has been denied, they receive an impersonal form letter that informs them that they can, of course, feel free to request for further information regarding the denial. Be sure to write and ask for further information and/or clarification, while informing they denier that you and/or the client are not going to accept this decision. Both therapist and client (or parents or guardian of the client) should do this. Both parties should be actively involved in this process. Let them know that they can not steamroll you and deny your client his or her rights.
Be polite but firm. Do not swear or make personal attacks. Do, however, be adamant. Make it so that it no longer is worth their while to deny the client's rights. Keep at them. Do not give in. The odds are that when you request further clarification of their denial of rights, you will receive another form letter that will not tell you anything new. Write back and point this out, and let them know that this is not good enough. Tell them that you have specific questions that you require specific answers to. Then clearly and concisely list your specific questions. Address them as much as possible to the flaws in the guidelines. Politely (at first anyway) demand that they explain themselves. The odds are, again, that you will receive nothing but a form letter in return. Answer immediately and let them know this is still not good enough. Let them know that they are not providing the kind of information and clarification that they have agreed to supply you. (In fact, check the client's contract with the insurance company to see what kinds of promises they make. Point out each and every one of these promises that they are now not keeping.)
All of this tedious, polite contentiousness has at least two objectives. One, as I noted above, is to keep a paper trail. If your situation is similar to ours in Massachusetts, the appeals process is multi-tiered. First the therapist must exhaust all appeals to the carve-out company (which is what MCC Behavioral is to the primary insurance company involved). Then the client must also exhaust all appeals to the carve-out. Only when both of those avenues are exhausted can the client appeal t the "parent" insurance company. This is what we ended up doing, and probably what you will end up doing. The paper trail will come in very handy at this point. You will have telling proof of the pain and suffering (important words, -- they have very legal implications) that the client has been needlessly put through in the process thus far. This especially true in the case of PTSD because this process can easily lead to retraumatization. As such it is possible reason for filing a legal tort for medical negligence leading to injury to the client. This is a very good reason to document any retraumatization that the appeals process puts the client through. Be sure to write about it to the people you are appealing to. That way it is in the record. Do so as early as possible in the process.
Another reason to keep peppering the insurance representatives with letters and faxes is to badger them, snow them under with paper. These people are not used to having their decisions questionned. They are used to dealing with volunerable people who do not know how to question their decisions. Therefore, they are not used to justifying their actions. More, they are not used to justifying their actions in any logical or legal manner. They will try again and again to bully you and the client. Politely but persistently do not allow them to do this. Insist that they give you clear and appropriate answers to any and all questions that you ask. The odds are that they will not do so. Indeed, they are not likely able to do so. That's okay. This is part of your evidence for the higher level of appeals. Just as importantly, this is part of the nettling process. These people are used to putting people off their guard. It is to your advantage to get them off their guard. They will not like this. They are more likely to make mistakes that will be in your best interests later on the in the appeals process.
While you are involved in the process of peppering the insurance company with paper, be sure to enlist help from elsewhere. I had my local state representative write a letter to the head of the insurance company. She was glad to do so after I explained the problem and sent her a summary of the interactions with the company thus far. I also called lawyers to find out what possible legal recourse we might have in the case. It turned out we didn't have much, but I did learn about the possibility of filing an individual tort due to negligence leading to medical injury. You might also note that your federal representatives and senators are likely to be less than useless. At best this is a state issue in the United States. By the way, I am well aware that this is a problem the world over, not just in the United States.
Be aware that no insurance company can insist that a client take part in any treatment. The client has a right to refuse any and all treatments. Unfortunately, the insurance company may be able to weasel out of paying for treatment, too, if this is the case. But I suspect this could be difficult to carry off if the therapist has a treatment plan that the client is willing to engage in. In our case the company simply wanting to medicate at first. The client absolutely refused. And the empirical literature backed the client up. There is little to show that medication of any sort can do more than ameliorate some symptoms. Talk therapy is still an important part of treatment, and the company did not want to pay for this. Besides the client had other reasons for refusing medications. So then the company wanted to force EMDR on the client. When it was pointed out to them that their own guidelines indicated that they are not allowed to demand experimental or unproven treatments, we were told they had a database of 50 articles on EMDR's effectiveness. So the therapist requested a copy of this database, and I critiqued it. It turned out that a large percentage was in Dutch, which we doubted anyone at the company could even read. The greatest number were articles printed in EMDR newsletters! Of the rest, only one had used adequate methodology to study the problem (I should know; I am a research psychologist, and this is my field). Moreover, that study excluded people for so many different kinds of conditions that the resulting sample did not really represent very many people likely to be seeking treatment. So the lesson here is question, question, question.
As the article in this newsletter on Treatment Recommendations indicates, we don't really know all that much about what does or doesn't work when treating kids with PTSD. But one thing we do know, cognitive behavioral therapy is the only treatment that has been shown to be effective. Even EMDR advocates are starting to claim it as a type of cognitive behavioral therapy (although I personally have my doubts about this, at least if it is used in isolation from actual talk therapy and other cognitive behavioral approaches; in which case, what good is it?). There are some published treatment guidelines, however. Notably those published in the Journal of Child and Adolescent Psychiatry (referenced in the article on treatment recommendations).
Do not let insurance company's bully you and your clients and keep you from doing what you know is best for the client. Fight back. Please.
Both the American Psychological Association and the American Psychiatric Association are concerned about this problem and would like to hear about any problems you encounter. Both associations also have legal counsel available who can provide some limited help. Moreover, the American Psychological Association has some grant money available (in the $5,000 to $10,000 range, I believe) to help people pursue legal challenges to insurance decisions.
Problems with insurance companies are not just a problem in the United States. I have heard from people from all over the world who are having the same problems. If you have had such problems and want to share how you handled them, please contact me. I will consider sharing your experience -- and hopefully your solutions -- with everyone else.
By the way, we won our appeal and MCC Behavioral was required to provide the full amount of services the client had coming. Not only that, but I believe we had a hand in getting the two people at MCC Behavioral in Massachusetts who were known to be roadblocks in the process (I want to Insurance Nazis -- okay, so I did) -- anyway, they were "let go" some time after our appeal. I'm not sure whether or not our case had anything to do with it, but I suspect it didn't hurt. I have heard from other therapists across the state that these two jerks were incredibly difficult to work with. I personally don't believe they deserve to be called psychologists. If I weren't afraid that there might be innocent people out there with their names, I would publish them here with the hopes that they never get another job in this field for as long as they live. Nor in any other lifetimes either.
You might also be interested in visiting the Mental Health Consumer Concerns web site. This group is a nonprofit corporation providing patients' rights advocacy services.