Residential Treatment Center (RTC) Insurance Denial

Page Contents:

• What Are Residential Treatment Centers and Who Do They Serve?
• Does Insurance Cover Residential Treatment and Why Are Claims Denied?
• What Should You Do if Your Insurance Coverage is Denied for Residential Treatment?
• What Companies Are Known to Deny Residential Treatment Claims?

What Are Residential Treatment Centers and Who Do They Serve?

Residential treatment centers allow individuals to experience 24-hour care while pursuing therapy that addresses eating disorders, addiction, alcoholism, and substance abuse. Residential treatment centers allow patients to have access to a higher level of care, away from the stresses of their home lives. Stays in residential treatment centers usually range from 28 days to six months and beyond. Residential treatment centers provide safe, effective care for those who have suffered profound adverse consequences resulting from substance abuse-related issues as well as other issues.

Behavioral, emotional, and mental health needs are all addressed for those who check in to a residential treatment center through individual and group therapy sessions, along with family therapy. Some residential treatment centers offer activities such as equine-assisted therapy and art therapy or alternative treatments like medication, yoga therapy, or acupuncture. Although RTCs can be a true lifesaver for many, residential treatment center insurance denials can leave individuals feeling hopeless.

Sometimes, instead of or after a residential treatment program, a provider may recommend counseling, an intensive outpatient program, or a partial hospitalization program.

Does Insurance Cover Residential Treatment and Why Are Claims Denied?

One of the primary issues surrounding residential treatment centers is the cost. These centers can be quite expensive, making treatment for those who really need it prohibitive. Under the Mental Health Parity and Addiction Equality Act passed in 2013, health insurance companies are expected to provide increased coverage for those seeking inpatient treatment for mental health issues and substance abuse issues. Coverage for RTCs is supposed to be equivalent to coverage provided for injuries and illnesses.

Insurance companies may do everything in their power to avoid paying the cost of residential treatment center programs. Insurance companies may use “lack of medical necessity,” as well as the following reasons:

• An unapproved facility was used
• No prior authorization was obtained
• An out-of-network provider was used
• Experimental services were provided
• The cost was higher than the insurance plan limit
• There was a higher level of care than required

What Should You Do if Your Insurance Coverage is Denied for Residential Treatment?

If you have been denied coverage for a medically necessary residential treatment center, you do have certain options. You can submit an appeal to your insurance company. If the appeal is unsuccessful, you can pursue an external appeal to further challenge the denial.

It is extremely helpful to have an experienced insurance denial attorney from the Law Offices of Scott Glovsky to help you get the treatment you need and deserve. Scott has two decades of experience helping people in similar situations and will fight for your right to get the treatments you need, regardless of how big or powerful the insurance company is.

What Companies Are Known to Deny Residential Treatment Claims?

While any insurer could potentially deny your residential treatment center claim, some are more likely to do so than others. Several years ago, Blue Shield of California and its claims administrator wrongly restricted patients’ access to residential mental health treatment and faced a class action lawsuit as a result. Violations of accepted professional standards as well as violations of the health plan terms were found during the investigation. Our firm filed a class action lawsuit against Kaiser for denying residential treatment. Among other things, the settlement required Kaiser to provide over 100,000 California policyholders living with severe mental illness access to medically necessary residential treatment.

The “fail-first” approach used by Blue Shield was found to be inconsistent with standards set by professional groups. If Anthem Blue Cross, Blue Shield, Aetna, Kaiser, Health Net, UnitedHealthcare, or other health insurers deny residential treatment center claims, contact attorney Scott Glovsky from the Law Offices of Scott Glovsky. We have litigated against insurance companies for denying residential treatment. And we will fight for your rights, your health, and your future.