Action Plan for Overcoming Insurer Obstacles

The various tools available here are provided with one goal in mind: that your health insurer will cover medically-necessary care for as long as that care is necessary with timely access to the right clinician(s).

Action Plan – Step by Step

With common sense and the resources provided by Cover My Mental Health, encouragement for overcoming insurance obstacles may be right around the corner.

“Common sense” says that your insurer ought to cover medically-necessary care for as long as that care is necessary with timely access to the right clinician(s). Of course, deductibles and co-pays may apply, though those are not the obstacles that need to be overcome.

The action plan supported with the resources of Cover My Mental Health begins with having documentation showing, for example:

  • Your clinical care is medically necessary;
  • No in-network provider is available;
  • Denials related to telehealth; or
  • Other evidence of an insurer raising an inappropriate obstacle to your care.

 

Resources from Cover My Mental Health help with this documentation.

Next in the action plan is talking to your health insurer, well prepared to potentially remove an obstacle to care.

Based on your documentation of the obstacle, Cover My Mental Health provides suggested paths to resolution of the obstacle, including:

  • Getting your insurer to recognize that care is medically necessary; or
  • Confirming that an out-of-network provider is an appropriate source of care when no in-network provider is available.

If an initial attempt is not successful, then filing a format complaint with your insurer may be appropriate and helpful.

When you are unable to remove the obstacle in discussion with your health insurer, potential help may be available from government or from your employer.

Cover My Mental Health identifies state and federal resources specifically available to help with insurance company obstacles, with key discussion points you should be prepared to share.

Additionally, for health insurance provided as an employee benefit, consider asking your employer for help related to this important employee benefit; template letters are provided for these communications.

The Cover My Mental Health action plan provides guidance for considering more significant approaches for “pushing further with your insurer,” specifically:

  • Insurance appeal
  • External appeal (following an unsuccessful initial appeal)
  • Single case agreement
  • Lawsuit

 

Considering these more significant approaches likely requires specific understanding of your insurance policy and local laws. As such, Cover My Mental Health offers useful background regarding these possibilities, though does not offer legal advice.

Tips for Success

  1. Leave clinical questions to the clinicians – if a customer service rep asks about how you (or your family member) is doing, try “Thanks for your interest, but I’ll leave that to the doctors.” As they say, anything you say can be used against you.

  2. Write down the name of the customer service rep – ask for their ID or badge number OR a case/call number

  3. Take notes – what did they tell you, if they promised something when was it promised, what did you tell them.

  4. “No, thanks. I don’t want your help with an appeal.” – If a customer service rep asks about whether you are now filing an appeal, say “no, thanks.” “Appeals” have special meaning with health insurance. Your rights to a formal appeal may be negatively impacted by an over-the-phone appeal.

Template letters available on Cover My Mental Health can be downloaded into Word, then customized to meet your requirements.

The templates are intended to minimize the amount of customization required.

Instructions are provided with each template; the instructions should, of course, be removed from the final letters.

Three reasons for having a copy of your complete insurance policy:

  1. An insurance company customer service rep may tell you something about your policy that you want to check; you can ask a customer service rep to tell you what page to find what they are telling you
  2. Policies may include information relevant to the obstacle you are facing, such as:
    • Availability of in-network providers
    • How they determine medical necessity
  3. Appeals procedures and rights are spelled out in the policy


Your health insurer is required to provide you with a copy of your complete policy:

  • It is likely more than one-hundred pages long. Summaries are not enough.
  • It may be called Summary Plan Description (SPD), Certificate of Coverage (COC), Evidence of Coverage (EOC), or maybe something else.
  • If the policy is not available online through an online portal, request a copy from an insurance company customer service rep.


 Template to request insurer provide copy of policy.

Overcoming insurance company obstacles will require some homework.

And it may be very important for you to “show your work.”

Documents and notes to keep track of include:

  • Invoices from your provider
  • Explanation of benefits (EOBs) received from your insurer
  • Notes from discussions with customer service reps
  • Medical necessity letters
  • Copy of your complete insurance policy
  • Any other documents received from your insurer


Important notes from a call with an insurance company customer service rep include:

  • Name and ID number of who you talked to
  • Case number (they will provide this)
  • Phone number you can use to call them back
  • Date of the call
  • Any commitment you heard regarding when they would follow-up
  • Any instructions you are given for next steps and any specific timelines mentioned.

It might help to have a trusted friend or family member work with you to deal with insurance issues.

Insurance company websites will typically have a downloadable authorization form for you to sign to authorize someone to help you.

  • Ask a customer service rep to provide you with an authorization form
  • Or download a document on their website called:
    • Designation of Representative Form;
    • Authorization Form;
    • Authorized Representative Designation Form; or
    • Something similar