good questions to ask
Joanne Cohen
7 Questions To Ask Your Employer's Benefits Manager
You as a consumer often don't discover what your managed care
plan or health insurance plan
covers until you need services. This is especially true for
mental health care and substance abuse
treatment. You can find out what is covered -- and not covered --
by asking the benefits
manager in the human resources or personnel department where you
work. Knowing what to
ask can be difficult. The following list of questions and
guidance may be helpful:
1) Benefits. If you have not already received information about
your health plan, ask your
benefits manager for a copy of your health plan benefits; you
have a right to have one of your
own to keep. Does this document describe what mental health care
and substance abuse
treatment benefits you are entitled to? Does it explain how to
get services and how to appeal
coverage decisions you do not agree with? Does it explain what
your financial responsibilities
are? Is the coverage equal to that offered for other illnesses?
2) Professional Expertise. Ask your benefits manager which mental
health professionals are
covered by your plan. Does the plan cover a full range of mental
health professionals? What is
their training and experience? Are they licensed or certified?
What kinds of treatments are
available? What treatments are excluded?
3) Contractual Limitations. Ask if there are any financial
agreements or arrangements that
the professional has had to make with a third-party payor or
insurer that could interfere with or
influence their treatment decisions. Is the professional in
danger of being discharged from the
plan for advocating your optimal care? Does the plan pay the
professional the same amount
regardless of treatment prescribed? Does the plan reward the
professional for limiting services?
4) Appeals and Grievances. If you have concerns about the
certification or authorization of
treatment decisions made by the payor or insurance company, ask
how you can appeal them to
the payor, your employer or the purchasing agent, or to outside
regulatory agencies. Ask what
methods you can use to complain if you don't agree with the care
provided by the professional.
You have the right to complain to regulatory boards and/or
professional associations which
have grievance processes, and you have the right to air your
complaints to your union, your
state and federal legislators and to the media.
5) Confidentiality. Find out if the information to be disclosed
to the payor would be anything
other than diagnosis, prognosis, type of treatment, time and
length of treatment and cost. Will
the organizations receiving this information keep it as
confidential as the mental health
professional? How will they protect it? Are there penalties for
disclosing information improperly?
If your information is transmitted, stored or used for any
purpose as data, will information that
identifies you be removed to protect your privacy? Will the
information be transferred to others
or sold?
6) Choice. Ask if you are able to choose any licensed/certified
professional for your mental
health care services. What professionals are covered and what are
their credentials? What if you
choose a licensed professional not usually covered by the plan?
7) Treatment decisions. Is anyone besides your professional
involved in your treatment
decisions? If so, do they have the same training and experience
as your treating professional?
Do they have a financial interest in the decisions they make?
These questions are based on a "Bill of Rights" developed by ten
major mental health
professional organizations to protect individuals seeking
treatment for mental illnesses and
psychological disorders. For further information, contact Lucy
Sanchez in Public Affairs at
mailto:lsan...@naswdc.org.
niki
Niki
KATHRYN A TAUBERT
>
Does this document describe what mental health care
> and substance abuse
> treatment benefits you are entitled to? Does it explain how to
> get services and how to appeal
> coverage decisions you do not agree with? Does it explain what
> your financial responsibilities
> are? Is the coverage equal to that offered for other illnesses?
Very good questions. What this does raise is the issue of claims payments
for 'mental health' vs biological conditions.
For example, if treatment for TS is claimed under a 'mental health' code,
the claims paid may be only that which would be normally paid for a 'mental
health' condition.
However, if TS is claimed under a 'medical code', then full reimbursement
will be paid as it would be under any other 'biological' condition.
(Depending upon the state).
Therefore, if a person gets a DX from a mental health worker per se, and the
claim is rated on a mental health code, which some mental health workers may
HAVE to use, then that may affect the amount of money the patient will
receive in compensation.
Therefore, there may be monetary reasons why patients would want to get an
MD to 'endorse' the DX, if for no other reason than to insure proper claims
payment?
KAT in CT
pwi...@inetnebr.com
KATHRYN A TAUBERT wrote:
>
> >
> Does this document describe what mental health care
> > and substance abuse
> > treatment benefits you are entitled to? Does it explain how to
> > get services and how to appeal
> > coverage decisions you do not agree with? Does it explain what
> > your financial responsibilities
> > are? Is the coverage equal to that offered for other illnesses?
>
> Very good questions. What this does raise is the issue of claims payments
> for 'mental health' vs biological conditions.
> For example, if treatment for TS is claimed under a 'mental health' code,
> the claims paid may be only that which would be normally paid for a 'mental
> health' condition.
> However, if TS is claimed under a 'medical code', then full reimbursement
> will be paid as it would be under any other 'biological' condition.
> (Depending upon the state).
> Therefore, if a person gets a DX from a mental health worker per se, and the
> claim is rated on a mental health code, which some mental health workers may
> HAVE to use, then that may affect the amount of money the patient will
> receive in compensation.
> Therefore, there may be monetary reasons why patients would want to get an
> MD to 'endorse' the DX, if for no other reason than to insure proper claims
> payment?
> KAT in CT
KAT, not entirely so . . . it depends on the insurance plan. Example, our
son has been treated by a pediatric neurologist since 1996. Just recently
the medical insurance company has carved out TS as a mental health
condition and will not cover costs of services by this MD for this
condition. Go figure. Ready to do some major battling. Right now they
are saying it does not matter who the treating professional is, it's the
code of the diagnosis. We have lost ground in this area. GRRRRRRRR
Pat W
KATHRYN A TAUBERT
Just recently
> the medical insurance company has carved out TS as a mental health
> condition and will not cover costs of services by this MD for this
> condition. Go figure. Ready to do some major battling. Right now they
> are saying it does not matter who the treating professional is, it's the
> code of the diagnosis.
Yep, that too. I know that a psychiatrist can code it 'biological' and a
neurologist can do that also. And some underwriters will pay the costs
according to the 'medical' code vs the 'mental health' code. What I suspect
is the case is that when a social worker 'codes' the condition, it doesn't
matter what the 'code' is, it depends upon, in this case, the treatment
provided, since social workers are not allowed to provide the same kinds of
treatments as MDs, in terms of medical testing, medications, etc.
Sounds like your underwriter is doing the same thing with MDs.
Also sounds to me like you have an HMO or one of its derivations? (PPO, etc)
KAT in CT
pwi...@inetnebr.com
>
> Just recently
> > the medical insurance company has carved out TS as a mental health
> > condition and will not cover costs of services by this MD for this
> > condition. Go figure. Ready to do some major battling. Right now they
> > are saying it does not matter who the treating professional is, it's the
> > code of the diagnosis.
KATHRYN A TAUBERT wrote:
>
> Yep, that too. I know that a psychiatrist can code it 'biological' and a
> neurologist can do that also. And some underwriters will pay the costs
> according to the 'medical' code vs the 'mental health' code. What I suspect
> is the case is that when a social worker 'codes' the condition, it doesn't
> matter what the 'code' is, it depends upon, in this case, the treatment
> provided, since social workers are not allowed to provide the same kinds of
> treatments as MDs, in terms of medical testing, medications, etc.
> Sounds like your underwriter is doing the same thing with MDs.
I hope I am understanding what your saying. The neurologist is not
providing any psychiatric treatment -- purely pharmacological. So that's a
bit disconcerting that the insurance company is not covering his service.
>
> Also sounds to me like you have an HMO or one of its derivations? (PPO, etc)
Just this year the insurance offered was under a PPO plan for the medical
with MH carved out to be covered by another insurance provider. The first
thing I will be checking on is how the neurologist's service was coded. It
is possible they inadvertently used the wrong code -- at least different
than what they had been using.
Pat W
KATHRYN A TAUBERT
> I hope I am understanding what your saying. The neurologist is not
> providing any psychiatric treatment -- purely pharmacological. So that's
a
> bit disconcerting that the insurance company is not covering his service.
Yes, and you should challenge this with the underwriter's medical director.
Claims CAN be challenged. Get your doctor involved with this challenge as
well.
> >
> > Also sounds to me like you have an HMO or one of its derivations? (PPO,
etc)
>
> Just this year the insurance offered was under a PPO plan for the medical
> with MH carved out to be covered by another insurance provider.
I have a real problem with these kinds of arrangements. It's subcontracting
the insurance to another company which can make it very difficult to know
precisely what you are getting without additional work on your part.
The first
> thing I will be checking on is how the neurologist's service was coded.
It
> is possible they inadvertently used the wrong code -- at least different
> than what they had been using.
Yep. Again, challenge this decision. Adjudication of claims is often a
subjective matter, done by a claims rep who may or may not have all the
facts. Claims can be challenged, and sometimes even reversed. Generally
speaking, when a challenge occurs, the company's medical director becomes
involved (an MD). It's best to have your own MD write a letter directly to
the medical director: doctor to doctor, so to speak. Good luck, and keep us
posted.
KAT in CT