Given the fact that insurers are bringing back “the old” egregious claims practices, it’s a good idea to review a few “best practices” for managing behavioral health claims.
Nearly all Employer Group ERISA Plans limit mental health benefits to 24 months. In addition, these policies also contain provisions that define “subjective symptoms” in one way or another. Therefore, it is extremely important to learn, or receive help, when filing mental health claims.
First, let’s deal with actual psychotherapy notes. Amendments to HIPAA have given mental health providers many options when it comes to providing actual treatment notes to outside third-parties. Although most therapists and psychiatrists know they are not required to give in to insurance demands to provide therapy notes, they often provide actual session notes, sometimes without patient Authorization.
I am referring to the Unum practice of sending its General Authorization, which clearly states, (…does not include actual psychotherapy notes), to providers with a request for actual psychotherapy notes. Therapists do not often actually read the Authorizations they get, so the notes are provided.
I have never recommended providing treatment notes to insurance companies. If you knew that your therapy notes were being provided to an insurance company, how truthful, and forthcoming would you be in your therapy sessions? In addition, Prudential, for example, grossly misrepresents the content of therapy notes and denies many mental health claims illegitimately.
Your mental health providers can refuse to send actual treatment notes, but must continue to support disability by filling out forms (referred to as “in summary form”.) Keep in mind that once these session notes are provided to an insurance company, you cannot then refuse future requests because you know better, or have better information. Your treatment providers have “one shot” at this to communicate what they will, or won’t do when it comes to providing actual psychotherapy notes.
Disability insurers learned a long time ago they could garner profits denying “subjective” complaint claims. “Subjective” means that there exists no tangible tests, lab testing or otherwise that will prove or back-up what you say you have. Migraines is a good example because there are no tests that can prove the etiology of pain, or frequency of migraines. Diagnoses based on “what the patient tells physicians” is also subjective and could possibly be limited to 24 months of benefits.
If insurers have begun to do what I think they have, there will be a resurgence of mental health denials alleging “subjective symptoms”.”Clinical diagnosis”, meaning a therapist”s diagnosis based on longstanding medical history, can be considered credible, but you have to know how to support a claim like that. Look for the “subjective symptoms” provisions in your Plan because these are well-known as “gotcha” provisions.
Those diagnosed with behavioral issues should note that surveillance is conducted quite often on mental health claims. Insurers think those diagnosed with “depression” should be in bed with the comforter up to their noses. This is simply not true. Every mental health claim I’ve assisted lists daily physical activity, and remaining social as part of the official treatment plans. Unum once denied a M&N claim because my client was observed having sex in the woods with a date. Since the therapist supported maintaining “normal social activities” the claim was eventually overturned on appeal.
A mental health claim, paid for 24 months can give claimants time to file for SSDI, get approved and replace disability income at the end of the 24 month period. This is always a good idea.
Claimants who are taking prescribed medication for behavioral issues should not be speaking with any representative on the phone. These conversations are unreliable and claimants are often taken advantage of. All communications should be in writing.
Supporting mental health claims is always more involved than physical claims. In my experience it always seems as though insurers know claimants have limited capacity and endurance to complete lengthy forms, or keep up with the system.
All mental health claimants should seek out assistance when the claims process “becomes overburdening” and too much to handle. Remember, insurers MISUSE mental health claims BECAUSE THEY ARE PROFITABLE.
