Carrie: Today we’re talking about an interesting topic, which is using insurance to deal with your mental health. And I have Joe Feldman here from Cover My Mental Health. So tell us a little bit about your story in terms of what is Cover My Mental Health. How’d you get started with this?
Joe: Carrie, thanks so much for hosting me. Cover My Mental Health story begins in a way that won’t surprise you or your listeners. It starts off with a situation that our family faced. One of our kids, as a teenager, needed more care than we were able to organize locally, and so, on the recommendation of a clinician, we found a residential program that was the right fit.
And not long after that residential program started, we got a letter from our insurance company that the care was not medically necessary, and therefore they would not be paying for it. We knew they were wrong, and clinicians also knew that they were wrong. So we stayed in the program. We used our savings to do that, and we began our pushback against the insurance company, including with a medical necessity letter, an appeal, and ultimately with a federal lawsuit.
We won all the way to judgment here in the Northern District of Illinois. I live just outside Chicago. That taught me a lot of things. It taught me that, first of all, litigation is a terrible way to enforce your rights under a health insurance policy. And I also learned slowly about steps that can be taken before litigation, before an appeal—steps that you can take right away.
And it was on the back of that that I started Cover My Mental Health at the beginning of 2024. Our mantra is that with Cover My Mental Health, you do not have to take no for an answer with your health insurance company.
Carrie: That’s great. I know in the past I worked with children and families, and we were really trying to prevent kids from going into residential treatment. You have to try all of these different things. A lot of times with the insurance companies, you have to show that you’ve tried this level of therapy or that level of therapy or this level of medication and all these different things. So it sounds like in your situation, you guys had exhausted all of those resources already, and residential really was the next best fit for your child.
Joe: That’s exactly right. We, I’d say like others and like you just articulated, jumping to residential treatment is probably not indicated in very many cases. And certainly it was not in our case. We tried a number of different therapists and programs locally, and none of them was working. And we were very concerned about our teen’s recovery, even their life. So that was, I’ll say, a step-by-step approach, and our insurance company, I’ll say, was aligned with us up to the moment that we pursued a higher level of care.
Carrie: Now, the process that a lot of clients that I’ve heard usually go through is they start calling around providers, and usually providers, especially with OCD, a lot of them don’t take insurance. They’ll say, “Okay, well, I can’t take insurance. We can bill out of network. I can give you a superbill, and you can submit that to your insurance company, and you might get something back.” And people have, depending on their coverage, they may not have any out-of-network coverage. They may get like a very small percentage back.
It just—there’s a lot to navigate, and I think many times people don’t even go that route. If they can afford it, they pay out of pocket, and if they can’t, they just don’t seek treatment, which, of course, is obviously heartbreaking and what we want to try to prevent, especially when people are paying this money for insurance. Tell us a little bit about what people can expect from their insurance company.
Joe: I would say any of us that have health insurance don’t really think about what our specific expectations should be. When things go well, we look in the directory, we find a clinician, we get care, the claims are paid, everything goes smoothly. There’s a deductible or a copay—we understand that, it’s all part of the situation.
When things don’t go well, then it’s important really to think about what’s a reasonable expectation. So certainly, for starters, having a clinician who has the right competence to take care of us and has an appointment available sometime soon, somewhere near us—those are all completely reasonable expectations.
There are some states that mandate by law the proximity, both in time and distance, that an insurance company has to provide, and the idea that a specialty level of care should be provided. That’s just common sense.
It’s also, I would say, common sense that an individual, either as a patient or a family member helping another family member—whether a child or a spouse or a sibling—might look in the directory and do their homework to see if there’s a clinician who is available in-network and available soon and near.
So the first thing that I really encourage people to do, and certainly in the OCD community this is essential, is to document that you have tried to find a clinician and to document what you learned. One of the features of the Cover My Mental Health website is that we have a series of downloadable worksheets and template letters and scripts and other resources that can help people along the way.
One of the resources we have is a worksheet that you can use to document your search for a clinician—a simple chart, a simple worksheet where you write down the names of clinicians who would appear to be available to you, and to document how that outreach went. Did you succeed in getting an appointment, in which case you’re done and it’s all good? Or did you learn that individual is actually not taking new patients, doesn’t offer an appointment until a year from Thursday, is actually no longer practicing, or maybe never was in the network and there was a mistake that they were in the directory?
Doing that homework and documenting it is going to be an important step to be able to then go back to the insurance company to request a waiver or a single-case agreement or some other recovery, if you will, where the insurance company takes responsibility for that basic expectation: “We’re going to provide you with access to the right clinician.” So you do your homework, and then they’ll do theirs.
Carrie: Yeah, I think this is pretty common, what you said, even about there maybe being somebody on that list that’s not up to date—that you don’t get a phone call back, or you find out, oh, that person has left the practice, they moved out of state, those types of things. People don’t always go on and update their information as a clinician, or it may be somebody that’s over a group practice who is responsible for that, you know, going in and updating that information.
People may call, and a lot of times people say, “I called through,” and sometimes they don’t get a call back. And also there may be clinicians that have marked that they treat OCD, but then we find out they don’t really have any training in ERP. They don’t have any training in ICBT. They don’t have what someone needs in order to get better, especially if they’re dealing with a more severe case.
Or maybe someone finds out they work with someone for a little while and they’re like, “Well, I’ve kind of done what I can do,” and then there might not be anybody else in that area on the insurance. I know that this puts a lot of burden on the individual who’s already suffering, right? Who’s already just like, “I’m struggling, I’m depressed. Maybe I feel hopeless. I don’t know if I’m ever gonna get better.” If you are wanting to pursue using your insurance, there is some legwork that has to be done.
Joe: I think that’s unfortunately true. It’s not a situation where the insurance company is providing, I’ll say, a concierge service where they’ll speak with you and then they’ll connect you with exactly the right clinician and schedule an appointment and make sure that it all works out.
One of the resources that I think all patients and families might want to be aware of is your health insurance company will have, on their website or by request through a rep, an authorization form that will give you the ability to authorize a friend, a family member, or a neighbor to act alongside you in dealing with the insurance company.
So it’s similar to a healthcare power of attorney. It could be very specific to certain needs, and it’s not something that should be necessary in every case, but it might very well be necessary in the case that you just described, where the family or the patient is already overwhelmed with their challenges and the idea of one more project with insurance.
The resource that is available to you is a friend or a family member who can help out and do some of that legwork for you. That’s something that I’ve shared in presenting the resources of Cover My Mental Health to clinicians especially, and clinicians are really very excited to be reminded that that’s a step they can encourage their patients to take when they need just a little extra help—and help may be just somewhere nearby.
Carrie: Yeah, that’s really good to know. So if someone goes through this process, and I know that we have a lot of people that listen to the podcast who are in more rural areas where they don’t have a lot of access to providers that might work with OCD. There might be some more generalists that can work with anxiety and depression, those types of issues.
Let’s say somebody has maybe exhausted that resource list. What do they say to the insurance company? I’m assuming they call back and say, “Hey, I’m really struggling to find a provider that has an opening in my area.” Then what?
Joe: What we obviously can’t do is just create instant and nearby availability when someone is, let’s say, living out in the country and there just aren’t that many clinicians who are expert in OCD. In fact, there may not be that many clinicians for many specialties, and so the expectation of either needing to travel or to use access by telehealth—those may be steps that are worth considering and are better than the alternative of doing nothing.
So that’s obviously a very individual decision that has to be made. One of the things that might be very helpful is for an individual who is looking for that higher level of care, that higher level of expertise, to have their primary care physician or maybe a clinician who they used to work with, who’s no longer available or no longer has sufficient expertise, write a letter.
It would be a specific type of medical necessity letter to say, “I’ve been taking care of Joe for some period of time, and Joe’s clinical needs are as follows—X, Y, Z—and the kind of care that Joe needs for his recovery is essential, and the risk of not providing that is very problematic.” And to be specific about that.
That’s a resource that the individual can bring to their insurance company to validate that the specifications—the particular characteristics of the clinician that they’re looking for—are not just their own personal opinion; they’re the opinion of a clinician who they’ve already been working with and who has made this recommendation based on that clinician’s expertise. That might be helpful in the mix, in addition to a worksheet that documents—
Carrie: I think that’s good because maybe someone goes to therapy, this happens quite a bit, and they just think they have some anxiety. And then as the clinician starts to dig in a little bit, they realize, “Hey, maybe this isn’t just generalized anxiety. Maybe this is OCD.” Hey, I could see you if you had the anxiety, but I’m thinking we’re not making much progress on the OCD, obviously, with what we’re doing here. Let’s try to refer you elsewhere.”
And then that clinician may really struggle to find providers as well. And I think that the documentation is—what you’re getting at is—so key. So tell us about that documentation process and how crucial that is.
Joe: Documentation is really important along the way because it removes ambiguity. So, for example, as we discussed, when you have looked in the network directory and you can’t find a clinician available to you soon, near, and with competence, what better way to establish that than to have notes?
My recommendation—and a recommendation you’ll find on our website—is always to document your conversation with health insurance customer service reps. We recommend writing down certainly the name of the person you’re talking to, their ID number (which they will provide you—sometimes reluctantly, but they will provide that to you), the date of the call, the substance of the call, what was agreed, and anything specific that they may have told you about their support for your looking for a clinician.
So documentation’s really important. Having documentation from a clinician that the care that is medically necessary is X, Y, Z—that’s really important, and that can be important on the occasion of searching for a clinician. It can also be important on making sure that the care that your clinician has identified as appropriate for you is, in fact, covered.
Health insurance policies—every one that I’ve ever seen—has language in it that says, “We will pay for care that is medically necessary.” It doesn’t necessarily say who’s going to decide, and on what basis, care is medically necessary. Having a clinician document their expertise, their practice (which makes them competent to determine what care is appropriate, what care is medically necessary) can be really, really important.
Carrie: It’s interesting because sometimes there will be medical reviewers for these types of things, right? Like the insurance company hires people to review information or documentation to see if a particular service is medically necessary. And I always find that somewhat interesting because obviously that person is taking whatever notes or things that are submitted—information that’s submitted—but they haven’t actually typically seen that person, maybe talked to them. They’re just reviewing that information.
And so if you have someone in your corner that can provide that documentation and who has worked personally with the client, I think that’s really important. You’re having to look at: what is this person’s history? Have they tried different levels of care? Have they had to be hospitalized because they were having a panic attack—like had to go to the ER anyway because they’re so distressed?
And I think insurance companies, a lot of times, they are trying to prevent people from going into higher levels of care. So if someone can be treated on an outpatient basis, obviously that’s what we want as providers, but then also the insurance company—that’s going to be more cost-effective for them than someone going to some type of residential treatment or even intensive outpatient program.
Joe: I mean, you’ve raised a lot of great points. One thing that I’ve learned from numerous conversations with clinicians is that the insurance company reviewers, and the insurance company more broadly, are concerned about crisis stabilization and not so concerned about treatment to recovery. And those are two very different objectives.
And yet the idea of focusing solely on crisis stabilization is not how medicine is practiced. It’s not how clinical care is practiced. It’s not how any clinician is trained. That’s just not sufficient. And so a medical necessity letter—and information that’s shared in a peer-to-peer review—should first and foremost focus on: what are the needs of the patient?
To be able to have that conversation between a clinician who is treating an individual and a clinician who is representing the insurance company—that’s just a very reasonable sort of topic of conversation. They should be first focused on what is the need of the patient, what is the overall context around which those care decisions are being made by the treating clinician and being observed and, say, commented on by the peer.
Once there’s an agreement there—if you don’t have an agreement there, there’s no sense talking about coverage—then you can have a conversation about, “Okay, so what care is going to be covered, and on what basis?” First and foremost, we should be focusing on the patient.
Carrie: I think that’s a really good point. It is a very different approach because in the medical world, I think we understand this and it’s a little bit more clear-cut. If someone goes in and has a heart attack, we need to know what caused the heart attack in the first place, how to prevent future heart attacks—not just, “Oh, okay, well, let’s recover from the heart attack and then go home and everything’s good.”
I mean, you know, similar in the mental health space. We need to get at what’s underlying here and look at ongoing care versus just preventing you from getting in a higher level of care. Let’s say the insurance company—you’ve gone back and forth with them. You’re really in the belief system of trying to prevent people from going to litigation, because that’s a long process, it’s hard to find a lawyer that will take on your case potentially. I mean, there are different roadblocks to that.
As far as what would be another step that people could do—are they asking for a supervisor at the insurance company? In the past, I’ve asked people, if you’re not resolving something with customer service, can you escalate this to the next person above you? What does that look like?
Joe: The recommendation that we have is to file what’s called a formal insurer complaint. This is not an appeal, and it’s also not a regulatory complaint—I’ll mention that separately. It’s called a formal insurer complaint.
Actually, it’s something that I did not know anything about until I was putting the resources for Cover My Mental Health together and talking with a friend of mine who used to be with three different health insurance companies. He ran— for each of those three companies—and he’s been a really helpful resource based on his experience having been on the insurance company side. In the meantime, I have some other, I’ll say, former insurance industry whisperers who have also been helpful with different observations about what’s happening on the other side.
So a formal insurer complaint is an opportunity to say to the insurance company—and it doesn’t have to be to a supervisor; it can be to whoever you’re talking to—that there’s an issue here that needs to be resolved and that I think the insurance company is getting it wrong.
For example, if the conversation is about finding a clinician in-network, the conversation might go something like this: “I’ve looked into the network directory and I can’t find a clinician who has the expertise to take care of me or to take care of one of my kids. I’ve tried, and I’ve got a document of my attempts to find someone, and I’ve just not succeeded.”
And maybe there’s been one conversation with the insurance company, or maybe more than one, and the insurance company is saying, “Well, maybe you should just, I’ll say, make do with some inferior level of care.” In a conversation, you can say, “I want to file a formal complaint, or a quality of care failure,” and then this would be followed up in writing.
The point of the formal complaint is to get the attention of the insurance company in a way that other steps may or may not. What I’ve learned is that a formal complaint trips an obligation on the part of the insurance company to report that complaint to two different organizations. They are obliged to report a complaint—a formal complaint—to their accreditation body and to their regulatory authority.
Insurers are operating in a regulated environment, and they have to maintain their accreditation to be able to operate as a health insurance company. That accreditation is probably by one of two organizations—one is called NCQA and the other is called URAC (U-R-A-C)—and they’re obliged to report all formal complaints and what was the disposition of those complaints.
Insurance companies simply don’t like to have to do that, so you’re getting their attention in a way that can be helpful to focusing on what is the need that needs to be addressed. The same is true of the obligation to report a formal complaint to their regulatory authority. Even though those obligatory reports probably don’t happen until the end of the calendar year or the end of the fiscal year, there’s an immediate obligation to keep track, and that’s where insurance companies might have their attention heightened to deal with you and to say, “No, no, no, let’s not file a formal complaint. Let’s just take care of this and get it done.”
That’s a really useful step that someone can take. By the way, we’ve shared this step with clinicians, and at the recent International OCD Foundation conference there was a clinic from Texas in attendance, and they heard me talk about formal complaints. The story of their successful use of this formal complaint is now on our website in the Success Stories section.
Carrie: Wow, great.
Joe: So the clinician and the patient and the insurance company had reached an agreement, so the care was being given out of network, but there was an agreement that documented what the care was going to be and what the payment terms were going to be, and so on.
And all that was going along smoothly—until it was time for the insurance company to pay. And this clinic in Texas was having trouble getting the insurance company to follow through on the agreement. As you can read on our website, someone in the clinic said, “You know, I heard this guy at the conference, and he said we should file a formal complaint.” And so they started that conversation, and the insurance company said, “Oh, you know what? In that case, we’ll get a check out to you right away.”
Carrie: Wow. So there are times where the insurance companies will pay for out-of-network care through some different avenues that you talked about. What is that called?
Joe: It can go by different names. Sometimes it’s called a waiver. There might be, in a health insurance policy, provision for the insurance company to grant a waiver—which is to say a kind of exception that care is going to be provided outside of the network under a certain set of circumstances.
It can be called a single case agreement—sometimes that term is used for exceptions—so it could be called something different altogether. I also want to be a little bit careful in not implying that there’s always a solution that’s going to be completely satisfactory for the patient, the clinician, and the insurance company. I wish that were so.
I think realistically, some clinicians who are expert may not participate in an insurance network, and the insurance company’s offer of how much they’re prepared to pay and how much the individual is able to pay may not close the gap and make that care available. I like to think that we’ll even the playing field and improve access to care, but I also want to be realistic that it’s not a 100% guaranteed solution.
Carrie: It’s not a perfect system. And so what you’re saying is the insurance company has a certain dollar amount that they believe that these services are worth, essentially, and that they’re willing to provide for that care, and then the clinician may be charging more. So it would be on the patient responsibility to still fill in that gap of extra money, which they may or may not deem as helpful enough to them. That kind of what you’re saying?
Joe: Let me mention two other potential steps that individuals or their families can take that could be helpful and could, I’ll say, extend the number of instances where you are successful gaining access to care.
The first I want to mention is constituent services. This is an avenue that many people might not think about, but it turns out can be very helpful. So our elected officials at both a state and a federal level have, as part of their constituent-facing services, someone in the office who takes calls from constituents—or maybe takes messages over the internet. They’re there to help individuals navigate either government or regulated industries, for which a health insurance company is certainly one example.
And so the idea is to reach out to constituent services—it could be a state representative or a state assembly person, depending on the state, or a state senator. It could also be the U.S. Senator or a member of the U.S. House of Representatives. I don’t have any specific advice about which might be most helpful, but you can reach out and see which one is appropriate. I think I’d probably have a small bias for going local first, unless there’s a relationship.
And essentially saying to the person in the elected official’s office, “I have a problem, and I need your help. I’m looking for OCD care for one of my family members. I have a letter of medical necessity that documents exactly the kind of clinician that is necessary. I’ve looked in the network directory, I’ve had a conversation with the insurance company, I even filed a formal complaint, and that didn’t get their attention, and so I’m interested in any help that you might be able to provide me.”
That person on the other end of the phone very likely is going to want to help and might be in a position to call the insurance company and essentially say, “What are you doing to my constituent, and can’t we get this resolved? Your job is to take care of their health needs in finding a clinician who’s appropriate and doing it on a financial basis that’s acceptable and reasonable based on what the individual thought when they bought the policy—and you can help me out.”
I’ve had that conversation with my own state representative. Again, I was making a presentation at the NAMI Texas Annual Conference. A woman who was attending that workshop stood up and said, “This is exactly right. That’s my job. I take those calls from constituents, and when they tell me the homework that they’ve already done and I can use that to call the insurance company,” she said, “it’s my pleasure to do that.” And she said, “I get results, usually pretty quickly and pretty successfully.”
I have a short video on the website that I took after she made those comments in this workshop, and I said, “I’d love to have you share that by video,” which she did. So that’s a potentially great step for individuals to take.
Another step is to file a complaint with a state or federal regulator. Those don’t necessarily move things along quickly, but they do get the attention of another authority that the insurance company has to have some respect for. Filing a formal complaint alerts the regulator that there’s a problem. You’re able to describe what you’ve already done yourself—you’re not looking for someone to start from square one—so that’s another step that can be taken that might be helpful.
Carrie: I think all of this is really great information that we don’t know—just being the average consumer of healthcare. It’s almost like you’re pulling back the curtain and giving us the behind-the-scenes tour of how some of these things work. That’s really good. I think it empowers people to know that they don’t have to continue in their suffering, that there are other options for them if they feel like, “Hey, I just absolutely can’t afford this out-of-network care,” that I’m hitting roadblocks.
Joe: I’ll say at the core why I started Cover My Mental Health: people are discouraged. Patients, family members—even clinicians—are discouraged that insurance companies wear us down and then we give up. And the whole idea is to provide encouragement that you do not have to take no for an answer.
Our resources are available at no cost and are things that people can act on right away. And I’ll go back to the authorization form—if reaching out to an elected official, for example, or saying to an insurance company, “I want to file a formal complaint,” if that’s a level of, I’ll say, conflict or stress that’s just a little bit too much, it could be that that’s something that friend or family members can help you with, and with an authorization form, they can proceed and help you out.
We certainly try to make our resources as easy to understand as possible and as encouraging to use as possible, and we’re hoping that as a result, people can get into action and even the playing field with their health insurance companies.
Carrie: That’s great. So people can go to covermymentalhealth.org and find all these resources and the different forms that you talked about today.
Joe: That’s right. We’re a nonprofit. We are supported by private individuals and by clinicians. As the founder, I’m still providing financial support and take no salary. All of our resources are available at no cost.
We have emails on the website where individuals can make suggestions about additional resources that might be helpful. Those have been really useful to us in developing new tools and adding new explanations—always trying to make it, say, just a little easier to access, just a little bit more straightforward. That’s our goal.
I come from a tradition where we say, “If you’ve saved one life, you’ve saved the world.” And that’s, I’ll say, my guiding light. We want to have someone go to our website every day—or maybe just once—find the resources that they need to make a difference for their care or for their family’s care, or, in the case of clinicians, for their patient’s care. And if that access to a resource makes the difference in their recovery, then all this is worthwhile.
Carrie: Yeah.
Joe: Absolutely.
Carrie: Well, thank you so much for coming on and sharing today.
Joe: Thanks, Care, so much for the work that you’re doing and for the broad community that you serve, also with faith and encouragement that there’s a better path forward, and we’re gonna get after it.
