← Tony Mantor: Why Not Me ?
Tony Mantor: Why Not Me ?
Joe Feldman: Overcoming Mental Health Insurance Roadblocks
00:26:08
Overcoming Insurance Obstacles for Mental Health Care with 'Cover My Mental Health' In this episode, the founder of the nonprofit 'Cover My Mental Health' discusses their mission to help patients, families, and clinicians navigate and overcome insurance obstacles to access mental health care.
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- [00:01]
A
Happy Holidays. Want to give your host a gift? Consider subscribing, rating and reviewing the show this holiday season. It really helps the show grow from all of us at Believe. Have a Merry Christmas everyone and a happy holiday.
- [00:25]
B
Welcome to why Not Me Embracing Autism and Mental Health Worldwide hosted by Tony Mantour, broadcasting from the heart of Music City, usa, Nashville, Tennessee. Join us as our guests share their raw, powerful stories. Some will spark laughter, others will move you to tears. These real life journeys inspire, connect and remind you that you're never alone. We're igniting a global movement to empower everyone to make life lasting difference by fostering deep awareness, unwavering acceptance and profound understanding of autism and mental health. Tune in, be inspired and join us in transforming the world one story at a time. Hi, I'm Tony Mantour. Welcome to why Not Me Embracing Autism and Mental Health Worldwide. Joining us today is Joe Feldman. He he's the founder and president of COVID My Mental Health, a nonprofit that's arming families, clinicians and advocates with free resources like medical necessity, letter templates, appeal scripts, and insider tips to smash through those barriers. His own journey started in a fight for his own family's care and led to a groundbreaking federal lawsuit that forced an insurer to reverse wrongful denials. He joins us to tell his story, his strategy, and how it led to his advocacy to help others. So before we dive into our episode, we'll be back with an uninterrupted show right after a word from our sponsors. Thanks for joining us today.
- [02:11]
C
Absolutely. I appreciate your inviting me. I look forward to a conversation.
- [02:15]
B
It's my pleasure. Glad to have you here. If you would tell our listeners what you do.
- [02:21]
C
I am focused on helping patients, families and clinicians overcome insurance obstacles to mental health care. If you do not have to take no for an answer, I think that's.
- [02:30]
B
Something we all can appreciate. So would you expand on what that actually means? And then most important, how do you accomplish it?
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C
Sure, with pleasure. So I started Cover My Mental Health as a nonprofit early in 2024 with the realization that there were no resources available to patients and families at the point of an insurance crisis. By insurance crisis, I mean a denial for not medically necessary or not being able to find a suitable clinician in your insurance network. Situations like that, you don't obviously know what to do and the obstacles stand in the way of care. And insurance companies really only provide one mechanism for dealing with disputes, and that's an appeal. And appeals are not suitable for getting started with those obstacles, getting out of the Way so over my mental health is all about providing encouragement that you don't think no for an answer and then resources to back it up. Resources that you can use today to push back on insurance companies.
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B
I think this is really great. What's your first approach? And then of course, how did you get started in this?
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C
So I got started in a way that doesn't surprise anyone. Our family had a real challenge. One of our kids needed more care than we were able to locate at home. And on the recommendation of psychiatrists, we thought a residential program that was suited their needs. And very shortly after the program started, we got a letter from our insurance company that said that the care was not medically necessary and they weren't going to pay for it.
- [03:59]
B
I wish I could say that's not surprising. So what happened from there?
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C
We knew they were wrong and we used our savings to stay in the program and to be sure that our kid got the care they needed and to deal with the insurance company later, which I certainly recognize is a bit of a luxury. Not everyone has the ability to do that. And we did deal with the insurance company later. We won a federal law lawsuit three years later, and our insurance company then paid the claim that they should have paid for in the first place.
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B
I'm happy to hear that you did get reimbursed. What happened from there?
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C
That thrust me into the world of advocacy because I thought no family should have to go through what we did and litigation while we were successful at it. Litigation is a really terrible way to access the kind of care that you should naturally get when you by a health insurance policy.
- [04:50]
B
With all that happening, what were some of the things that you gained out of that? As they say, knowledge is a powerful tool.
- [04:56]
C
Turns out there are many steps that can be taken to overcome those obstacles far short of litigation. We don't guarantee that they all will work immediately, even at all. We do believe that our resources will even the playing field. And we've been at it now since our website went up in May of last year. And really pleased with the testimonials that we've received from both the patient and clinician. Use of our resources to overcome obstacles.
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B
Since you started this, do you get involved with people that are just local to your area or have you expanded to include anyone, no matter where they are, across the country?
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C
So our resources are relevant for all 50 states and for all private insurance. That's a. I'll say. A big part of what we tried to do was to make our resources as universally applicable as possible. And to make it easy for individuals to, when they get to our website, to see the challenge that they've got right on the website, so denied, not medically necessary or no suitable clinician in network, and to be able to press that button and have it open up into resources that they can begin to use right away.
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B
Now, when you say resources, can you expand on that some? Is this resources to help them against a possible insurance claim that they might have to do, or is it resources that will help them find the people that they need, no matter what it is to help them with themselves or a family member?
- [06:28]
C
So our resources are ultimately focused on patients, and sometimes that means their families. In many cases, the resources are relevant for clinicians to be involved in. Best example of that is overcoming a denial or similar obstacles related to medical necessity. So a core resource that we offer is a template medical necessity letter. This template letter provides the language and the structure for a clinician to write a letter to the insurance company that explains who they are, introduces themselves, their practice, their interactions with the patient, their assessment of what the patient's course of treatment should be, including some risks that might be encountered if the treatment does not proceed, and then their sign off on the care that is appropriate, the care that is medically necessary. So that's a document that was developed with input from a wide range of clinicians and appeals experts and litigators, former insurance company executives, state and federal regulators. And the idea is that it is a way for clinicians who have never written a medical necessity letter, which by the way means pretty much all to see in this template, you know, a common sense of explaining who they are and their ability to make a decision about clinical care and then to provide that to the insurance company. And we know that these letters work said we don't guarantee that they work every time, but they work.
- [07:58]
B
Now, this form that they can fill out and submit, does this help them with just a single patient or does it expand to more of them being within the network of that insurance company so that way they can help more people down the road.
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C
So our resources are focused on individual cases, to help individual patients in the case of directories that are incomplete or misleading. That's a real challenge for higher levels of care where there's not a residential program, for example, in network, or an intensive outpatient program in network or for certain specialty care. OCD care, for example, is mostly available experts who are not participating in insurance networks. Now, insurance companies are obliged to provide access to appropriate clinicians, and we do provide resources to help A patient or a patient's family to document that they have looked at the directory and they have done their homework to determine whether they can find an appointment somewhere soon and nearby with someone who's got the right expertise, and if they can't, to be able to then show their homework. A worksheet that we developed to impose upon the insurance company the obligation to find a clinician who's available. It's definitely a challenge because so many clinicians don't participate in insurance networks for a variety of reasons. The main one is if they don't have to and they can run a practice without doing so, that might just work for them, but it doesn't. Doesn't work for all the patients.
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B
How does this work? When you have someone that really, really needs a lot of help, then the insurance company, with their infinite wisdom, decides, we don't want to help. So the person needs the help. Unfortunately, you're fighting with the insurance company to get the help. Meanwhile, that person that needs the might be falling behind. And if that happens, it could be a travesty. How do you avoid that?
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C
Right. One of the observations that we share to deal with this, or at least to try, is to remind patients and clinicians especially that an authorization form is available for every health insurance plan so that someone can authorize a friend or a neighbor or a family member to be on their team from a, say, a legal standpoint and to be able to work with the insurance company. So I know when our family has been through challenges with either or both of our kids, we have enough friends and family and neighbors who say, is there anything we can do? You guys must be going through quite a tough stretch. Can we drive the carpool? Can we bring you a meal? And the answer could be, you know, for the right friend or family or member or neighbor. Do we authorize you to help us a little bit with the insurance? And by the way, here's a website that might give you some ideas of what to do. It's not to hand the responsibility off to someone entirely, but it's hand someone to the team. And it's not to make final decisions about anything. It's to help with some of the just basics of asking for a copy of the insurance policy, interacting with the insurance company with regard to, say, a medical necessity letter, submitting that to the insurance company on a timely basis, that sort of thing. That could be a big step that people just lose track of because no one ever told them, by the way, there's an authorization form that you can use to envy your team.
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B
When you get under the mental health umbrella, you have ocd, adhd, anxiety, bipolar, schizophrenia, so many different things. Does this cover all that?
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C
It does, it does. And in fact, the principles that we rely on in terms of an insurance company contract says we'll pay for medically necessary care. Insurance contract says we'll provide you with a network of clinicians. All our resources are focused on those basics. And actually the resources apply to all health care, not just mental health and substance use disorder. What we know is that mental health and substance use disorder are particularly challenging for insurance coverage. We've estimated between 15 and 22 million mental health claims are denied every year by private insurance companies. That's just too many. So our. Our goal is to provide a resource that is, as I'll say, universal as possible.
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B
So what are the steps in this scenario? Let's say we have someone that is in psychosis. They need help, and they need it now in the worst way, because if they don't get it, you don't know what kind of tragedy could happen. Is there any way of speeding the system up some to get this person the help they need and still have the insurance company be part of it, right alongside them, helping them get through this?
- [12:46]
C
So our goal with medical necessity letters in particular, and I'll focus on that because that's right at the intersection of a clinician interacting with a patient. Our goal is to provide resources that empower that relationship to move as quickly as is appropriate based on that clinician's expertise and the patient's addition and preparedness to accept the care. When I talked to clinicians, I had an opportunity to present grand rounds at an academic psychiatry department earlier today. Talk about how medical necessity letters can be appropriate and valuable anytime a denial or a slow prior authorization or change in level of care is on the horizon. Physicians know from their experience when an insurance company is about to get in the way. And very often a medical necessity letter can anticipate that and hopefully preempt the delay and put a marker down about their competence to make the decision.
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B
You mentioned earlier that it took you three years to get this all under control when you had your issues. Does this speed up the situation so they wouldn't have to do that, or is there still a gap there that would create a situation where legal action, unfortunately, would still be something that would be on the table?
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C
I can certainly say I wish I knew then what I know now because that took a really long time and litigation is just not a great way to go. So we're with medical necessity letters. That's early and often. It really helped move things along.
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B
Do you have any examples that you can give us on how things can change because of this?
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C
For example, a psychiatrist who has used our resources presented at a. At a meeting that we had earlier this week, and she described how insurance companies would take a week or two to provide the initial prior authorization for many medications. ADHD was the particular medication for which she needed permission from the insurance company to provide to her patient using a transdermal patch, because that was the right delivery mechanism for this particular patient and she knew this insurance company was going to drag their feet. She used our template medical necessity letter to describe the patient's particular needs, and she got approval in 12 hours. And as she described it, that takes the delay out of the patient, their family, the clinician, they can get back to work. So that's a, you know, that's a, to me, a remarkable story.
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B
Yeah, that's what we need to hear. More stories just like that. This way they have a little hope.
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C
Another story that I've heard from another psychiatrist who's used our resources. She's found that when she has provided a medical necessity letter to an insurance company that the next time she has an interaction with a patient that has, I'll say, a similar situation, it goes just a little quicker.
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B
Yeah, that's really good to hear.
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C
I really believe that the systemic benefit of our resources will come from that sort of empowerment of patients and clinicians. Right. Because patients are confused because they deal with this only maybe once in their life or maybe only from time to time. Clinicians see this all the time and it's very frustrating and they're very discouraged. And to the extent that we can encourage and resource clinicians, it makes it more likely that the insurance company is going to know they're not going to be able to walk over this clinician. This clinician knows how to stand up for themselves.
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B
Now, the one thing about insurance companies, whether we like it or not, they have vast resources. How can we effectively challenge the immense financial power and influence of insurance companies with their vast resources, lobbying efforts and legal teams? How do you work around that and how does this impact what you're doing?
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C
Well, we're not going to solve that one overnight. So one of the steps that we suggest that has been helpful, I'll say, evening the playing field is filing a formal complaint with the insurance company. So a formal complaint is not an appeal and it's not a regulatory complaint. It's a formal complaint to the Insurance company. I wish I knew about this years ago. I only learned about this from some ex insurance company executives who helped guide the development of the resources that we put on our website.
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B
I'm very familiar with the formal complaint along with the state insurance commission that you could go to. Would you expand on that for those that might not know?
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C
So the formal complaint works like this. You say to the insurance company, it can be orally and then followed up in writing. I want to file a formal complaint. It'd be for a quality of care failure. It could be for some other interaction where the insurance company is, let's say, behaving badly. And insurance companies have two obligations when they receive a formal complaint and they don't like either one of these two, they are obliged to report the formal complaint to their regulatory agency. They're state or federal, and they're obligated to report the formal complaint to their accreditation body, which is the organization that licenses them to do business as a health insurer, probably your ACT or ncqa. NCQA is the bigger one for private insurance and they don't like to do that. And so saying I want to file a formal complaint is potentially more effective than saying, for example, I'd like to speak to a supervisor where you get a no, you get a no. Or a delay from someone that has a slightly bigger title.
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B
Yes, they sure do know how to do that. Do you have any examples of anything that you've done or been around where this has worked?
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C
So one example of a formal complaint working that surprised me in a really positive way was this. There is a clinic that specializes in OCD care in Texas and they are not in network. And they had worked out an agreement among the insurance company and the patient and themselves cover certain care at a certain rate. And that was all they needed to be able to proceed with the taking care of this patient. So all that happened. And then they sent the bill and the insurance company said, we're not paying. And then they said, we're not paying again. And then one of the members of this clinical staff heard a presentation that I made at the International OCD Foundation Conference. And I described, among other things, filing a formal complaint. So they went back home and they said to their colleague, let's try again. I heard this guy talk about formal complaints. Let's try it, because why not? But they had another conversation. Are you going to pay the bill? No. Okay, in that case, we'd like to file a formal complaint. And the insurance company rep said, the checks in the mail and they got Paid. That's a story. That's on the success stories link on our website.
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B
Yeah, that's great. Because anyone that puts the time in and does the work should get paid for doing it.
- [19:46]
C
To me, that was a bit of a surprise, right? Because like I said, I didn't know about this mechanism before putting this website together. And here was a scenario that I had not ever anticipated. So I don't know if that works in every case. Probably not so much. But to me the signal is this is a clinical organization that knows the words and is communicating with the insurance company on their level. And so that. That matters. That matters. So that's a. That's a step.
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B
Yeah, that's a great step. Anything that will work to help people get where they need to be. Are there any other avenues you've used to help people get the support they need?
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C
Another step that might be helpful against the wealthy Resource Unlimited insurance company is getting help from an elected official. So state senator, state representative or state assemblyman, U.S. member of Congress, either on the Senate side or on the House side. All these representatives, all these elected officials have a constituent services person in their office who takes incoming calls from their constituents and they try to help. And the idea is that insurance companies are regulated and the constituent services folks want to help. So if you've taken the first steps, for example, filing a medical necessity letter and they say, sorry, we're still not going to pay, and you file a formal complaint and they say, not good enough then to be able to call constituent services and say, I need your help because insurance company is standing in the way of care and I've done what's reasonable for me to do and I'd like to get your help. So I've validated this in a couple different ways. I had a conversation with my state representative and she told me that she takes calls in her office from individuals who are looking for help with insurance, among other issues. And she said, we love those calls because we get to help people by calling the insurance company and saying, this is such. And so from Representative XYZ's office and we want to know what you're doing to our constituent.
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B
Yes, that is just really good because sometimes that's what it takes is to get an extra person in there that's got a little more power to help them out.
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C
The other I'll say validation was a presentation that I made to a group at NAMI Texas. It was for their annual conference. And I described this step and a woman stood up in the back and said, I Just want to say that this is 100% true and it's my job. I work in the Texas legislature and I take these calls when someone brings me a story and tells me what they've already done themselves, because I don't start from square one. But when they tell me what they've done, I can call the insurance company. And she said, within a day or two, almost all the time, I get the insurance company to cut it out. I've got a video of her telling that story on the website. After she said that, I said, oh my gosh, that's awesome. Can I record you out in the hall afterwards? And she said, absolutely. She's just great, right? She's soft spoken, determined. You don't want to be on the other side of that, right?
- [22:39]
B
Absolutely. Don't want to be on the wrong side of her. Now. It's definitely great to get a chance to get out there and meet people and speak to them. What's some of the interesting things that might have been said to you at point one of your speaking engagements?
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C
I presented to a group of clinicians at the Menninger Clinic in Houston, which is one of the top mental health programs in the country. In the Q and a, there were 80 clinicians in the room and 20 more on Zoom. We had a great banter and it was really just super productive. And one of the clinicians near the end said, you know, this is all great, but I find you just sometimes have to get angry. I said, well, you should do whatever works for you. I can tell you this though. I don't know how to teach angry. I know how to teach common sense. I'm not really teaching you anything. I'm alerting you to what you already know. I've been trying to think about how. How to say that in a way that's sort of wizard of Ozzy, right? You have the ability to do it all along. Now we're going to get to it.
- [23:32]
B
Yeah, I think that's just great. And you just said it. So how do people contact you?
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C
Our website is covermymentalhealth.org we are a nonprofit. All of our resources are no cost. We have an email contactellumentalhealth.com you're welcome to use to send us your ideas. Certainly welcome contributions. But there's no cost to use our resources. And people can also say help by sharing our resources with folks who may benefit from them. Half of adults in America will encounter a mental health issue in their life. So we we being folks who can use these resources are everywhere. And just spreading the word would really be helpful. I'd be grateful.
- [24:11]
B
Now, in closing, what would you like to tell the listeners that you think is very important, not only about what you're doing, but how what you're doing can help so many people across the country.
- [24:24]
C
So I want them to believe that they do not have to take no for an answer with health insurance companies and that their common sense expectations of their insurance company are completely reasonable. They buy health insurance, they expect that there's going to be a network directory that they can use to identify clinicians. That's so basic. It's a reasonable expectation. They expect that those clinicians are going to be able to make decisions about their care that are going to be covered by insurance and that that's going to persist through their treatment plan as they have a higher level of care, new meds, a different location, some duration that should all be covered. And then they should. If the claim is paid, subject to deductibles and co pays, we understand that's part of the deal. And if there's a dispute, the dispute should be resolved with the patient in mind. These are all common sense expectations and you are your own best advocate. So a little bit of encouragement, maybe help from a friend or neighbor, but you are your own best advocate.
- [25:19]
B
Yeah, absolutely. Well, this has been great, great information, great conversation. I really appreciate you taking the time to join us today.
- [25:27]
C
Tony, I'm grateful for the conversation with you and to help spread the word. I come from a belief that if you save one person, you save the world. So if one listener benefits from this, we've had a great day.
- [25:40]
B
Absolutely. That's exactly the same way I feel too. I've really enjoyed it. Thanks again. Thanks for taking time out of your busy schedule to listen to our show today. We hope you enjoyed it as much as we enjoyed bringing it to you. If you know someone who has a story to share, tell them to contact us at WhyNotMe World. One last thing, spread the word about why not me. Our conversations, our inspiring guest, the show. You are not alone in this world.
- [26:29]
A
Happy Holidays. Want to give your host a gift? Consider subscribing, rating and reviewing the show this holiday season. It really helps the show grow from all of us at Believe. Have a Merry Christmas, everyone, and a happy holiday. If you like the show, please take a moment to rate, review and subscribe. It really does help the show to grow. Thank you for listening.