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Insurance Claims: Empowering Your Clients for Coverage

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Insurance coverage for mental health and substance use treatment has long been a challenge compared to coverage for physical health.  While federal and state laws have been implemented over the last several years to require parity treatment (i.e., mental health same as physical health), it remains far too common that claims are denied and coverage is out-of-reach for individuals requiring such care.  More recently, federal lawsuits have been won in favor of patients where insurers improperly, that is illegally, denied claims.  Step-by-step, the landscape may be shifting so that patients will be less likely to confront denied claims.  But we’re not there yet.

Insurers have denied claims for “lack of medical necessity” where that determination has been made independently of the patient’s treating clinician.  Such denials may be confounding to both patients and to their clinicians.  After all, who should be making the determination about whether care is indeed “medically necessary”?

Authors of a recently published article will describe their recommendation for clinicians to provide a “letter of medical necessity” to their patients as a tool to improve the likelihood that insurers timely approve claims.  Such letters have proven crucial in lawsuits and appeals; they represent an important tool that clinicians can provide their patients. 

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