Joe Feldman: Overcoming Mental Health Insurance Roadblocks

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world one story at a time. Hi, I'm Tony Mantor.
Welcome to Why Not Me? Embracing Autism and Mental Health Worldwide.
Joining us today is Joe Feldman. He's the founder and
president of Cover My Mental Health, a nonprofit di'sarming 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 and insure 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.
Absolutely, I appreciate your inviting men forward to a conversation.
It's my pleasure glad to have you here. If you
would tell our lists new is what you do.
I am focused on helping patients, families and posicians overcome
insurance obstacles to mental health care. If you do not
take no for an answer.
I think that's something we all can appreciate. So would
you expand on what that actually means? And then, most important,
how do you accomplish it?
Sure with pleasure? So I started cover my Mental Health
as a nonprofit early in twenty twenty four 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 hover my mental health is all about providing couragement
that you don't know for an answer, and then resources
to back it up, resources that you can use today
to push back on insurance companies.
I think this is really great. What's your first approach?
And then, of course, how did you get started in this?
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 to 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.
I wish I could say that's not surprising. So what
happened from there?
We knew they were wrong, and we used our savings
to stay in the program and to be sure that
our kids got the care they needed, and to deal
with the insurance company later, which I certainly recognized there
is a bit of a luxury. Not everyone has the
ability to do that, And we did deal with the
insurance company later. We want a federal lawsuit three years later,
and our insurance company then paid the claim that they
should have paid for in the first place.
I'm happy to hear that you did get reimbursed. What
happened from there.
That brushed 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 could naturally get when you buy a
health insurance policy.
With all that happening, what were some of the things
that you gained out of that? As they say, knowledge
is a powerful tool.
It turns out there are many steps that could 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 received from both the patient and
clinician use of our resources to overcome obstacles.
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.
So our resources are relevant for all fifty states and
for all private insurance. That's 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 do metically necessary or no suitable clinician in network,
and to be able to truss that button and have
it opened up into resources that they can begin to
use right away.
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.
So our resources are ultimately focused on patients and sometimes
that means they're families. In many cases, the resources are
relevant for clinicians to be involved in. The 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 or 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 patients of course, the 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 it's appropriate 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, skate and fteral regulators. And 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 a common
sense of explaining who they are and their ability to
make a decision about clinical care, and then to provide
that the insurance company, and we know that these letters work,
and we don't guarantee that they work every time, but
they were.
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.
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 otdcare 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 a 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
develop 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 work
for all the patients.
How does this work when you have someone that really
really needs a lot of help, then the insurance company,
where 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 a help might be falling behind, and if
that happens, it could be a travesty. How do you
avoid that.
One of the observations that we share to deal with this,
or at least to try, is to remind patients and clinditions,
especially that the 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 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 and
we drive the car pool. 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 had
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 the people just move track of
because no one ever told them. By the way, there's
an authorization form that you can use to be team.
When you get under the mental health umbrella. You have
ocd ADHD anxiety, by poll a, schizophrenia, so many different things.
Does this cover all that it does?
It does? And in fact, the principles that we rely
on in terms of an insurance company on track 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 healthcare, not just mental health and substancechief disorder.
What we know is that mental health and substance chef
disorder are particularly challenging for insurance coverage. We've estimated between
fifteen and twenty two million mental health claims are denied
every year by private insurance companies. That's just too many.
So our goal is to provide a resource that is
i'll say universal as possible.
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.
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 in
the patient's addition, and prepared us 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. BUS
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.
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.
I could certainly say I wish I knew then what
I know now, because that took a really long time,
and mitigation 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.
Do you have any examples that you can give us
on how things can change because of this?
For example, a psychiatrist who has used our resources presented
at 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 I 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 twelve hours. And as she described,
I do 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 to me a remarkable story.
Yeah, that's what we need to hear more stories just
like that. This way they have a little hope.
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 is an interaction with a patient that has
i'll say a similar situation, it goes just a little quicker.
Yeah, and that's really good to hear.
I really believe that the systemic benefit of our resources
will come from that sort of empowerment of patients and clinicians. Right,
because patients pagents 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 condissions, it makes
it more likely that the insurance company is in a
know they're not going to be able to walk over
this clinician. This clinician knows how to stand up to themselves.
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?
Well, we're not going to solve that one overnight. So
one of the steps that we suggest that has been
helpful of 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.
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.
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 normal complaint
it would 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 or their
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
u AT, NCQA and CQA is the bigger one for
private insurance, and they don't like to do that, And
so saying I want to file a normal complaint is
a tally more effective than saying, for example, i'd like
to speak to a supervisor where you get to know,
or a delay from someone that
has a slightly bigger title.
Yes, they sure do know how to do that. Do
you have many examples of anything that you've done or
been around where this has worked.
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 patients in
themselves of a 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 sumal complaints. Let's try it, because why not
whether 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
that checks in the mail and they got paid. That's
a story that's on the success stories link on our website.
Yeah, that's great because anyone that puts the time in
and does the work should get paid for doing it.
Tony, 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 there's a hit 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 step.
Yeah, that's a great step.
Anything that will work to help people get where they
need to be. Are there any the other avenues you've
used to help people get the support they need.
Another step that might be helpful against the wealthy resource
unlimited insurance company is getting help from an elected efficient
so state senator, state representative, or state assembly and US
member of Congress, either on the Senate side 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 constitution. 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, biling a medical new subsidy 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 X y Z's
office and we want to know what you're doing to
our constituent.
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.
The other I'll say validation was a presentation that I
made to a group at NAMI Texas who's for their
annual conference, and I described this step and a woman
strew up in the back and said, I just want
to say that this is one hundred percent true, and
it's my job. I work in the Texas legislature and
I take these calls when someone brings me this story
and tells me what they've already done themselves, because I
don't start from square one do 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 god, that's awesome,
and 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, 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 one of your speaking engagements.
I presented to a group of clinicians at the Metinger
Clinic in Houston, which is one of the top mental
health programmers in the country.
In the Q and a.
There were e clinicians of the room at twenty 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
teaking 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 lizard of Alsie. Right,
you have the ability to do it all along. Now
we're going to get to it.
Yeah.
I think that's just great and you just said it.
So how do people contact you?
Our website is covermmenttalhealth dot org. We are a nonprofit.
All of our resources are no costs. We have an
email contact at calldomondenttalhealth dot com. You're welcome to use
to send us your ideas. Certainly welcome contributions, but there's
no cost to use resources. And people can also say
help by sharing our resources with folks who made gonna
fit 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 a word would really be helpful.
I'd be grateful 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.
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. And by 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. If they have a
higher level of care, new meds, different location, cob duration
that can all be covered. And then if the claims
paid subject to deductibles and copays. We understand that's part
of the deal, and if there's a dispute, the speech
would 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.
Yeah.
Absolutely, Well, this has been great, great information, great conversation.
I really appreciate you taking the time to join us today, 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.
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
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