There isn’t another job I would rather have. Ever. I wake up every morning feeling blessed to come to a job that I love and do something every day that feels meaningful. Working with patients with eating disorders is something that I consider a privilege.
Despite my passion for the work that I do, my job comes with challenges – eating disorders such as anorexia and bulimia have the highest mortality rate of any other psychiatric disorders, recovery can take a long time to achieve, and patients are often resistant to treatment and recommendations. In spite of all of these challenges, probably the most daunting and time consuming task I and other eating disorder mental health providers face is obtaining insurance coverage for our patients that meets their needs in terms of level of care and time span of coverage.
Upon agreeing to treatment and completing the intake and assessment process, my staff and I determine which level of care (Inpatient, Residential, Partial Hospitalization (PHP), Intensive Outpatient, or Outpatient) is appropriate for each patient. The next step is contacting the patient’s insurer in hopes of receiving an authorization for the level of care in which the team feels is necessary for the patient to work toward recovery. Sometimes this is a very supportive process as some insurance companies understand the seriousness of eating disorders and what treatment typically looks like. Other times, however, it can be difficult to “convince” an insurer that a patient is in need of a higher level of care (Residential, PHP) unless the patient is suffering significant medical consequences as a result of their eating disorder. This is because insurers are often looking only at laboratory values and vital signs to determine medical necessity and not taking into account the patient’s need to remain in treatment longer in order to ensure continued stabilization or to be in a higher level of care in order to break the cycle of the eating disorder. In fact, according to research by Maine, Samuels & Tantillo (2015), “Adults with Eating Disorders can suffer medical complications quickly despite long-term medical stability and normal laboratory values, even resulting in sudden death.” One could certainly make a case that in the instances where an insurer asks that the patient be discharged prior to the patient, family and treatment team’s feeling the patient is ready to do so, the patient is put at high risk for early relapse and a need for continued treatment, thus requiring additional treatment episodes and, ironically, more cost for the insurer.
The patient and treatment team have several options when it comes to advocating for the treatment that the patient, family and treatment provider think is necessary. There are typically one or two levels of appeals that the treatment provider and also the patient can ask to complete. The number of available appeals and the exact appeal process differs depending on the policy of each insurance company. Some companies only have one level of appeal, others have two. Some companies ask that you submit a request for an appeal in writing, others do not. Each level of appeal is reviewed by a medical doctor who makes the final determination. A different medical doctor does each level of appeal in order to attempt to ensure objectivity. The state also typically has a health care advocate, which is often a state-funded team of folks dedicated to ensuring adequate health care is being received by state residents. The health care advocate can take over the appeal process at any time at the discretion of the provider. Once the provider has the patient’s permission to do so, the provider contacts the health care advocate and the advocate works to reverse the insurance denial.
One can contact the Office of the Health Care Advocate in CT at: ct.gov/oha or 866-466-4446
And in MA at: 888-830-6277
About the author:
Rebekah Bardwell Doweyko is the Director of Walden Behavioral Care’s South Windsor, CT Clinic. In this role, she is responsible for providing clinical, administrative and fiscal oversight as well as development for the clinic. Formerly, she was an Intensive Care Manager at the Connecticut Behavioral Health Partnership (Value Options, Inc.) in Rocky Hill, CT where she assisted providers in the treatment and discharge planning for patients identified as high utilizers of inpatient hospitalization and detox services, conducted clinical trainings on Eating Disorders for staff and managed CT Medicaid cases with complex Eating Disorder issues. Prior to this role, Ms. Doweyko has held several clinical positions at various facilities including founding and directing the Intuitive Eating Program (IOP) at Hollywood Pavilion Hospital in Hollywood, FL. She has also held various positions at The Renfrew Center in Coconut Creek, FL acting as a Primary and IOP therapist. There she developed the “Real-Life Excursion” program allowing patients to begin their transition from Residential treatment. Rebekah also specializes in substance abuse, and has worked as a Primary Therapist at The Caron Renaissance Institute and Alternatives In Treatment, Inc. of Boca Raton, FL. She was featured in the Emmy Nominated HBO Documentary “THIN” and composed the foreword to the highly acclaimed “Maintaining Recovery from Eating Disorders” Self-help book by Naomi Feigenbaum. She earned her Master’s degree in Mental Health Counseling from Florida Atlantic University in Boca Raton, FL and is a Licensed Professional Counselor in the State of Connecticut.