Getting Insurance to Cover Mental Health

Despite the existence of parity¹ laws mandating health plans to cover mental ailments comparably to physical ailments, denials and burdensome reviews interfere with treatment. As a practicing physician and mental health advocate, I often find that patients and clinicians are frustrated with barriers to necessary and deserved care.

The same is true across many specialties, and we've probably all heard horror stories of insurance companies denying life-preserving coverage. With mental health, which carries a stigma that already deters people from seeking care, the last thing anyone needs are more hurdles.

Additionally, the common symptoms of mental illness themselves make it hard for patients and families to endure the often long and grueling process of fighting for coverage. Coverage is often denied initially, requiring a protracted appeals process, and sometimes even the engagement of state regulatory bodies. Patients may give up and withdraw from treatment, especially if they have mental health challenges that undermine hope, motivation, and self-esteem.

The peer review process insurance companies use in considering a request for coverage is sometimes smooth but often befuddling. The reviewing doctor is often not a peer; in fact, they may be trained in an entirely different specialty and unqualified to evaluate the treatment plan. The reviewing physician may state that they are not denying the care; they are just saying that the insurance will not pay for it. Of course, such a response is beyond frustrating, because people are often paying a great deal of money up front for insurance coverage; it evokes moral outrage.

Add to that a growing list of whistle-blowers and lawsuits identifying problematic internal policies with insurers. And the slow pace of legislation, regulation, and enforcement, which delays needed treatment while illnesses progress—even if treatment is effective and ultimately covered.

The reality is grimly ironic, as health-economics analyses² show that providing mental healthcare substantially reduces future costs from mental and general illnesses.

Joe Feldman³ decided to do something about the state of affairs after facing difficulty ensuring coverage for his daughter's necessary treatment. He founded not-for-profit Cover My Mental Health (CMMH) to help others surmount insurance hurdles. For example, the group provides tools and templates for sending letters establishing medical necessity letters. I recently spoke with Feldman.

GHB: What is Cover My Mental Health and how did you start it?

JF: Cover My Mental Health is a nonprofit supporting patients and their families facing insurance obstacles to mental health and substance use disorder care. My family has faced and overcome insurer denials for healthcare. I’m aware of how overwhelming it is to face an insurer offering inadequate in-network providers, reversing prior authorization approvals, and denying claims for necessary care.

The commitment of Cover My Mental Health is to provide resources for pushing back, resources that are as easy to use as possible. Mostly, I started Cover My Mental Health with the desire to provide encouragement that you do not have to take “no” for an answer.

GHB: What are the main obstacles people face when trying to get mental health services approved?

JF: The two main obstacles are, one, no in-network provider is available and, two, denials for “not medically necessary.”

As a member of a health insurance plan, you expect that the clinician network will give you access to clinicians with the right expertise, somewhere close to you, and with appointments available soon. Sadly, too often this expectation is not met. It’s a challenge referred to as “ghost networks,” and it has been the subject of several high-profile studies and articles this year. RTI⁴ (Research Triangle Institute) reported that network-adequacy problems result in significantly higher use of out-of-network providers, at significant financial burden to members. ProPublica⁵ published a guide to help with ghost networks, including our worksheet for documenting troubles with finding a provider.

As an insured person, you expect that your clinician is competent and in the best position to evaluate what care is best suited to your needs. Clinicians refer to this as applying “generally accepted standards of care,” while insurers usually call it “medically necessary care." When insurers don’t agree with your clinicians, their denials may be for “not medically necessary.” These denials often lack any explanation of why they made that determination, so it be can particularly challenging to push back.

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GHB: What are some key strategies for facilitating the process of getting insurance claims for mental health services approved?

JF: I don’t know whether encouragement is a strategy, though I’d start with the importance of staying encouraged. The value of encouragement starts with clinicians. Having a bit of optimism will go a long way. That said, there are three strategies that are core to the resources of Cover My Mental Health.

The first strategy might be described as “show your homework.” This would include having a clinician provide a medical necessity letter to address a denial for “not medically necessary” or completing a worksheet documenting that you attempted to find an in-network provider using the insurance directory and were not successful.

The second strategy is to file a formal complaint with your insurer. This is not an appeal, rather a complaint. Complaints trigger reporting obligations to an insurer’s regulators and accreditation organizations. This step raises the profile of your objection within an insurance company, hopefully to your advantage.

Even unsuccessful formal insurer complaints may be helpful input for the third strategy, which is to take advantage of potential advocates. These include state regulators, federal regulators, and the constituent services offices of your elected officials.

GHB: What do you see as the main systemic issues, and what would you like to see change?

JF: First, there is still significant stigma associated with mental health and substance use disorders. And that stigma can make it hard for individuals or their families to push back on insurers.

Second, there are significant disincentives for clinicians to join insurance networks, particularly low reimbursement rates by insurers and complex, time-consuming processes. This was described in some detail in the ProPublica reporting.

And third, enforcement of existing laws and regulations is challenging and limited. This leaves insurers less accountable than they should be for supporting their members’ mental health.

GHB: Is there anything else you'd like to add?

JF: When you advocate for yourself or a family member, be sure to know that you are also advocating for others who may not or cannot. As more insurers hear from more patients, from their families, and from their clinicians, it becomes just a little harder for them to maintain their belief that they can wait you out and that you will give up.

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