Episode 3 of the Food for Thought mental health podcast is all about health insurance and answers the often-asked question, “Why won’t health insurance cover residential treatment?”
Host: Virgil Stucker.
Guest: Scott Leshin, founder and CEO of SJ Health Insurance Advocates. SJ Health Insurance Advocates is a health insurance claims management and advocacy firm based in New Jersey and serving families all over the country.
ABOUT THIS EPISODE
Medical insurance companies typically try not to cover needed mental health treatment beyond the average 7.2 day hospital stay during a crisis. Scott and his firm are helping families and providers to secure coverage for residential, specialty and community-based care… when it is needed. They try to get insurance companies to comply with the federal mandates requiring that those with mental illness be given treatment that is equivalent to treatments covered for physical illness.
The recording of this conversation with Scott was particularly timely due to a major ruling on Monday March 4th, in which a Federal Judge from California found that UBH of UnitedHealth Group created internal policies that impeded access to care for patients with mental health and substance abuse disorders to save money.
ABOUT OUR GUEST
Scott Leshin comes to this work with very personal experience: he founded this company after discovering firsthand how broken the health insurance industry is while trying to seek reimbursement for his son, Sam, who has cerebral palsy.
Scott received his Bachelor’s degree from Syracuse University and Master’s degree from NYU Stern School of Business. Prior to founding SJHIA, Scott worked on Wall Street for both Morgan Stanley and Goldman Sachs.
While working an intense full-time job, Scott was also managing the challenges and frustrations that came from navigating the health insurance bureaucracy. Through consistent and determined advocacy for his son, Scott continued to cultivate his knowledge and expertise of the health insurance industry.
After achieving success for his son (who he still fights for daily) and becoming aware that many other families also needed help, Scott launched SJHealth which now has 40 employees helping him to help families and mental health care providers nationwide to gain greater access to medical insurance resources for treatment beyond acute hospital care.
TALKING POINTS
The three main talking points addressed in this episode:
1. Framing the issue: why health insurance companies are so reluctant to cover residential treatment.
2. How can families be smart consumers, avoid pitfalls, and get the most out of their health insurance coverage?
3.Breaking news: California judge rules against United Behavior Health for discriminatory practices.
FOLLOW-UP QUESTIONS
During the live recording of this episode, we received more questions than we could answer. Below Scott has addressed each of the questions we did not have time to get to.
Question 1
Given that it’s all about the money – how do we make NOT paying more expensive? Penalties for denials? Currently if someone does actually sue & win, there are no damages for instance.
Answer
There are instances where insurance carriers are fined for their bad behavior. It is not uncommon. However, these fines are very small and the carriers save money by paying the fines vs the claims.
Question 2
Can you discuss a few case studies where getting coverage was successful? What sort of diagnosis did the person have and why kind of treatment did they receive?
Answer
Majority of cases are successful and this applies to all levels of care. You can find the Clinical Policy Guidelines online that demonstrate what a patient must present with to have the best chance for success. It is important to note that proactively seeking authorization leads to significantly more successful than retroactively seeking authorization via the appeals process.
Question 3
What have you found to be the average number of days insurance companies are willing to cover residential treatment for?
Answer
27 – 45 days
Question
Do you have hope that our healthcare system will turn away from volume-based care and towards a more preventative approach, like you just spoke about?
Answer
Our healthcare system is moving in this direction but the insurance industry is not. The two need to meet. This is the on-going battle. You see this more on the medical side. For example, wellness visits and flu shots are commonly offered for free from insurance carriers bc they are inexpensive and do save costs long term for the carrier. Conversely on the mental health side we are very far apart.
Question
Is it easier to get coverage if the parents have guardianship?
Answer
Past age 26 it is. Reason being is that the courts have already demonstrated the need.
Question
Is the answer universal healthcare?
Answer
In my opinion no. It’s failing in the countries that have it and there is too much dysfunction in our government to successfully administer basic programs let alone something as important has healthcare. This is a political issue which I like to stay away from.
Question
What can program leaders of residential programs who care do to help families with the health insurance mess?
Answer
Most programs do offer some sort of insurance assistance either in house or via a third party relationship such as working with firms like mine. Programs should also be tracking outcomes and conducting outcomes studies to offer proof to insurance companies as to the effectiveness of residential treatment.
Question
Regarding the court cases and what we hope can begin changes in the current lack of insurance coverage when needed – what can we do as citizens to help this movement? On the legislative side, we can keep sending the message to our representatives, but can we do anything to support forward movement of what’s going on in courts? Is this a battle that is better fought on state or federal level?
Answer
The more light we can shine on this issue the better. Be it contacting your representative or getting active in various advocacy groups.
Question
Is it correct that the in network rehabs are more regulated and more reliable than out of network facilities?
Answer
Regulation on quality of care does not fall to the insurance carrier. This is done on the state level. Both in and out of network providers can do a great job or a terrible job. It varies significantly from program to program.