Electronic Winter 2025 | Issue 65
Cover My Mental Health – A New Resource Supporting Clinicians Advocating for Patients’ Insurance Coverage
This interview was conducted by IPS Council Member, Dr. Karen Pierce.
Karen Pierce: Across my many years of psychiatric practice and teaching, the one skill that seems crucial to day-to-day practice that is completely missing from any medical training or curriculum is how to deal with insurance companies to be sure that patients are getting reimbursed for the care that is needed. Since you spend your days focusing on insurance and mental health, what are the most important insights you have for psychiatrists when dealing with insurance?
Joe Feldman: If there’s a single insight to share, it would be that medical necessity letters can be consequential with insurers and improving access to care. A medical necessity letter is a formal document that explains why a specific treatment is medically necessary for the patient. This sort of communication is akin to what happens in a prior authorization discussion. The difference is that a medical necessity letter more substantially anticipates how the clinical decision-making in the context of insurance claims determination should result in coverage.
A written medical necessity letter is based on the common-sense idea that a clinician should document their competence to make clinical decisions, their knowledge of generally accepted standards, and their determination of the appropriate care supporting treatment and recovery.
Clinicians can find encouragement with medical necessity letters and can spread that encouragement to their patients. With medical necessity letters, we can reduce the resignation of taking “no” for an answer.
Pierce: That sounds like incremental work for an already busy clinician.
Feldman: Cover My Mental Health provides a downloadable (and free) template letter to support clinicians with preparing a medical necessity letter. With the template, the time required to prepare a letter is dramatically reduced. Also, we know that time spent on the phone or waiting for a call from an insurer is an unpleasant burden on clinicians. With a medical necessity letter, time spent explaining the patient’s requirements, and repeating the story for yet another insurer contact, can be mitigated.
Pierce: That’s exactly my experience using your templates. The medical necessity letters are straightforward to prepare and have reduced time spent dealing with insurers. Most importantly, they work to secure coverage for my patients.
Feldman: That’s our goal!
Pierce: Going back to those calls with insurers… so-called peer-to-peer reviews… those can be particularly frustrating and time consuming.
Feldman: That’s not the first time I’ve heard that. Of course, peer-to-peer reviews are a critical moment of patient advocacy… an opportunity for a clinician to discuss with a true clinical peer (with the same training and experience) a patient’s required care in support of insurance coverage. One of the most exciting new resources we provide to clinicians is guidance for how to best prepare for and conduct a peer-to-peer review call.
Pierce: Got it. How did you get into this world of advocacy?
Feldman: Well, not on purpose. Nearly ten years ago, the psychiatrist taking care of one of our kids recommended residential care, a course of treatment that my wife and I concurred with. Shortly after starting the program, our health insurer cut us off. They said the care was not medically necessary. We knew they were wrong. After two unsuccessful appeals, we won a federal lawsuit against our insurer, resulting in their paying the claim they should have paid in the first place.
That’s not a path that I’d recommend to anyone, and it turns out to be a rather unusual way to get the insurance coverage you paid for. We overcame their opaque processes, denials without explanation, a third-party reviewer opining on care without any patient contact or knowledge, and challenging procedures for this kind of litigation.
This effort launched my interest in advocacy to encourage and empower patients and their families to not take “no” for an answer. It also made me discover the importance of teaching families and clinicians on how to do this important work.
Pierce: Isn’t there a law…?
Feldman: Yes. In fact, there are many laws. Most well-known, perhaps, is the Mental Health Parity and Addiction Equity Act of 2008… often called the Parity Act. That legislation certainly changed expectations and has improved access to mental health and substance use disorder care. However, no one can deny that parity access to care has not been realized.
It is unambiguously important for a clinician to advocate for their patient in crisis. Laws take years to change and that policy advocacy work needs to be done outside the scope of clinical care. The purpose of my organization is to facilitate the clinical process. Plenty of other organizations are primarily focused on changing and enforcing federal and state laws.
Bottom line, at the point of crisis like medical necessity denials, knowing that the law is on your side is insufficient. We have to advocate on a case-by-case basis, say with medical necessity letters, while also supporting enforcement of laws and regulations.
Pierce: What’s surprised you most from time working in this area?
Feldman: Most surprising (and confounding) is that the prevalence of mental health and substance use challenges… after all, who doesn’t have a close friend, family member, or co-worker with challenges including challenges related to insurance coverage. As a wise friend of mine likes to say, “We know better. We can do better.”
Dr. Karen Pierce is a board-certified child psychiatrist in Chicago and faculty member at the Feinberg School of Medicine at Northwestern Medicine.
Joe Feldman is the president and founder of Cover My Mental Health, a non-profit providing free resources to clinicians, patients, and families to overcome insurance obstacles to mental health and substance use disorder care.
Resources available on Cover My Mental Health website:
Please visit our website for a wide range of resources for clinicians supporting their patient advocacy to overcome insurance obstacles to mental health and substance use care.
· Website – www.covermymentalhealth.org
· Medical Necessity Letters - templates and guidance
· Guidance for Peer-to-peer Reviews
· Medical necessity letter template
· Patient hand-out featuring Cover My Mental Health resources
For any questions or inquiries regarding CME/CE-accredited workshops and other presentations, email Joe Feldman at joe@covermymentalhealth.com.