Eating Disorders: Seeking Treatment

Written by HealthyPlace.com Staff Writer

Navigating the System: Tips for Getting Treatment

Eating disorders can lead to significant physiological changes that require medical treatment in addition to psychiatric treatment and the reimbursement system does not allow for a holistic approach. For this reason, patients and families frequently have to fight to get the appropriate and necessary treatment.

Eating Disorders are very serious, potentially life-threatening problems. The current mental health care system's reimbursement policies and 'managed care' guidelines make it very difficult for eating disordered patients to receive treatment. These illnesses can have multiple causes, with possible physical or genetic predisposing factors, in addition to multiple psychological issues. The illness process leads to significant physiological changes requiring medical treatment in addition to psychiatric treatment but the reimbursement system does not allow for a holistic approach, wherein the costs of treatment might be more fairly shared between medical and psychiatric insurance benefits. Furthermore, some companies have very specific and inadequate guidelines for treatment, which fall far short of the current recommendations by the American Psychiatric Association (2000). Consequently, patients, families, and practitioners frequently have to fight to get the appropriate and necessary treatment. The following suggestions may help.

1. The most important first step is to have a complete assessment. This includes a medical evaluation to rule out any other physical cause for the eating disorder symptoms, to assess the impact the illness has had to date, and to determine whether immediate medical intervention is needed. See Table 1 for specific tests. Equally important is the mental health assessment, preferably by an eating disorder expert to provide a full diagnostic picture. Many people with eating disorders have other problems as well including depression, trauma, obsessive-compulsive disorder, anxiety, or chemical dependence. This assessment will determine what level of care is needed (inpatient eating disorder treatment, outpatient, partial hospital, residential) and what professionals should be involved in the treatment.

2. Pursue the recommended level of care. Ask your insurance company, HMO, and health care providers for recommendations for programs or specialists.

3. Find out about local resources for treatment by calling the National Eating Disorders Association Information and Referral Helpline at (800) 931-2237 or visit the "Referral" area of the web site www.NationalEatingDisorders.org.

4. If your company does not provide a benefit for the recommended level of care (some policies have inpatient and outpatient, but no residential or partial hospital benefit), ask them to 'flex the inpatient benefit.' Appeal this to the medical director of the company if you are denied. Also, speak to your employer, union, or human resources department. As they pay for your coverage, they can pressure the company to provide the needed service. Have your physician or specialist who evaluated your loved one write a letter documenting the level of care needed.

5. Record the date/time/name of all your communications with the insurance company. Put your requests in writing if they are initially denied. Keep copies of everything.

6. Insurance and managed care companies are governed by state laws but most states mandate an appeals process. Usually, you must file an "internal appeal" with the company. First, request a letter from the company stating that they have denied the coverage you are seeking. (You need this denial in writing). Also request an explanation of their appeals process. Read the membership book from the insurance or managed care company - if the service you need is clearly excluded, appealing the denial will be pointless. A letter to the medical director documenting the need for treatment and risks of not receiving it may, however, cause the company to re-examine their policy.

7. If this is unsuccessful, write to the state insurance commission and/or speak to an attorney. Provide copies of all documentation.

8. Consider getting the care recommended by arranging to self-pay, while you continue to pursue reimbursement.

9. If the insurance company approves treatment, but not in a specialized program, appeal this decision. Or, ask that the treating clinicians obtain supervision and training from experts in eating disorders. If this treatment does not result in significant improvement, ask that specialists provide further treatment.

10. If you have no insurance, local mental health clinics or departments of psychiatry at medical schools may be useful resources. Also, you can apply for state assistance, Medicaid, through your local Department of Social Services or for Medicare if you meet the criteria for disability. There are some research programs, which provide treatment for no cost, but you must meet strict criteria. Contact your local major universities or medical schools to find any local research or studies for eating disorders. Research studies are often posted on the National Eating Disorders Association web site www.NationalEatingDisorders.org.