Patients requiring eating disorder care may face insurance obstacles as with other mental illness. However, challenges specific to eating disorders may include: no suitable in-network clinician, coverage denials, delays in prior authorization, restrictions to care, and misinterpretations of labs. These resources provided by Cover My Mental Health may support your self-advocacy to ensure access and insurance coverage.
Below are reasonable expectations for your accessing in-network clinicians:
If no in-network clinician is available, you should pursue having an out-of-network clinician covered as if they were in-network. That may be the law in your state. It is, in any case, a reasonable expectation.
If you do not find a suitable, in-network clinician, ask an insurance company customer service rep for help, using these talking points:
Your request for coverage of an out-of-network clinician at in-network rates should be put in writing. AND, your insurer’s response to that request should also be sent to you in writing.Your insurer may call this a “waiver”.
Insurer request for in-network coverage for out-of-network clinician
If this does not result in a timely appointment with an in-network clinicians, then see “Filing a formal complaint with your insurer” for a next step.
Why file a complaint?
What a complaint is not?
A medical necessity letter is “[the] authoritative voice of a psychiatrist [or other clinician], backed by the law, [that] can push insurance companies to do the right thing.” So wrote Mark Moran in the Psychiatric News article “Medical-Necessity Letters Written By Psychiatrists Can Be Decisive.”
Access resources for overcoming medical necessity denials here.
These national organizations provided eating disorder-specific support and may be helpful for individuals and their families:
Alliance for Eating Disorders – https://www.allianceforeatingdisorders.com/
ANAD (Anorexia Nervosa and Associated Diseases) – www.anad.org
F.E.A.S.T. – www.feast-ed.org
International Federation of Eating Disorder Dieticians – https://ifedd.org/
National Alliance on Eating Disorders – https://www.nationaleatingdisorders.org
Sea Waves – www.sea-waves.org
Patients requiring eating disorder care may face insurance coverage obstacles requiring more substantial clinician advocacy to overcome these particular barriers to care, including in a medical necessity letter (see https://covermymentalhealth.org/denied-not-medically-necessary/). Additionally, patients with eating disorders experience comorbidity with other psychiatric disorders including depression, anxiety, obsessive compulsive disorder, post-traumatic stress disorder, self-harm behaviors, substance use disorder, and risk of suicide. Considerations related to care of co-morbidities are appropriately addressed in a medical necessity letter.
Resources provided here include a medical necessity letter template, guidance for overcoming eating disorder specific insurance obstacles, and guidance for peer-to-peer reviews
Advocating for eating disorder care may require a medical necessity letter that addresses specific insurance obstacles, such as provided below.
For your convenience, below are links to a template medical necessity letter and related resources:
