Exposing the Hard Truths: Insurance Claims Denials for Substance Use Treatment, with Mark DeBofsky
Host: Brenda Zane, brenda@hopestreamcommunity.org
Instagram: @hopestreamcommunity
Guest: Mark DeBofsky, President, DeBofsky Law
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About this episode:
Parents trying to navigate treatment with their kids are already pushed to their mental and emotional limits. When you're in it, you're so overwhelmed it's hard to think about something as frustrating and time-consuming as insurance. But my guest today reminds us the earlier you get started and the more thorough your documentation, the more likely you are to receive coverage for the treatment resources and services your child needs.
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Mark: [00:00:00] The letter of medical necessity is critical in these cases. ProPublica did a story a couple of months ago. Basically, AI is being used to reject claims, and these claims are being denied in seconds. The reason that they can do that is because the AI will look at the claim, and if there isn't an adequate letter of medical necessity, They can spit that claim out immediately.
Brenda: You're listening to HopeStream. If you're parenting a young person who misuses substances, is in a treatment program, or finding their way to recovery, you're in the right place. This is your private space to learn from experts and gain encouragement and support from me, Brenda Zane, your [00:01:00] host and follow mom to a child who struggled.
This podcast is just one of the resources we offer for parents. So, after the episode, head over to our website at hopestreamcommunity. org. I'm so glad you're here. Take a deep breath, exhale, and know that you have found your people. And now let's get into today's show.
Hello, hello. Glad to be here with you today.
And I'm actually ecstatic to be able to bring you some information about one of the most frustrating and exhausting parts of this whole roller coaster ride, which is not your child. But your insurance, you would think that this would have been resolved by now, that insurance companies would pay for our kids to get healthy and safe.
But no, it is not a universal thing that treatment gets covered and you might be at your absolute wits end, running around in circles, buried in paperwork, trying to get coverage for even part of your [00:02:00] child's care. It is infuriating and also completely unfair. I do a ton of research, finding guests to join me on the podcast, and I have been looking for a while for somebody who could once and for all, with a lot of credibility, explain to me.
And, to you, what the heck is going on with insurance companies, and more importantly, what we can do as parents to get more coverage for services that can save our kids life. I came across an article that I will link to in the show notes where Mark Dubrofsky, an attorney in Chicago, provided input about this issue and you know I immediately reached out to him before I'd even finished reading the article.
We had a conversation, and I asked if he would be willing to give me another hour of his precious time to record an episode, and thankfully he agreed, and that is what you're going to hear today. Mark is a member of the firm Dabrowski Law and has also [00:03:00] served as an adjunct professor of law at the University of Illinois Chicago School of Law since the year 2000.
He is a prolific author who has written many journal articles. And has been a regular columnist for Law 360 and the Chicago Daily Law Bulletin. Mark is also an annual contributor to the ERISA Survey of Federal Circuits, published by the American Bar Association, and served for many years as Senior Editor of Employee Benefits Law, published by Bloomberg.
Please do be sure to go to the show notes for this episode, because I'm linking to Dabrowski Law's website, which is simply Dabrowski. com. And they have tons of articles and resources there. And I'm also including several very important articles that Mark shared with me, one in particular about wilderness therapy.
You may want to save this particular episode in your podcast app because you're probably going to want to go back and listen to it again in the future. [00:04:00] And now, let's get to it. Here is me and Mark Dabrowski talking insurance. Enjoy.
Mark, welcome to HopeStream. This is a very, very important conversation I've been waiting to have with somebody who is well qualified for it. So I really appreciate you joining me today. So thanks for being here.
Mark: Well, thanks for having me. So
Brenda: we have a lot of families who are Uh, in extremely difficult positions, not only with their families, but with their insurance companies.
And so you and I had a little chat a while ago about this exact conversation, this situation that our families find each other in. And I thought it would be worth doing a deep dive with you because it is becoming more and more [00:05:00] common. And I think you have some great insight and answers and resources for people.
So before we get into all of that, Could you just give us a little background, like how did you end up getting into this world, I know you handle all kinds of claims, but in particular claims for residential treatment and, and wilderness therapy for families.
Mark: It was a natural evolution of the work that I was doing.
Initially, we were a little reluctant to get involved with health benefit claims. As it became apparent that the need was growing, we felt that we had an obligation to get involved in handling these claims and helping people who have these claims try and get them straightened out so they can get the benefits they need.
Brenda: And has there always been this much of a struggle with substance use and mental health claims, or I guess my question is sort of what's [00:06:00] changing, um, because it seems like there's a
Mark: lot going on. So the answer to your question is probably somewhat perverse, um, and I can't tell you that I know this for a fact.
But I think that the reason why this has become more acute, or a significant reason why this has become more acute, is the Mental Health Parity and Addiction Equity Act. Before that law was passed 15 years ago, insurance companies were able to get away with just offering blanket, or having blanket exclusions in their policies.
So, even if we wanted to do something to help patients, there was nothing that we could do. We couldn't supersede the terms of the plans. Now, this coverage is in the plans, but the insurance companies have worded the coverage in ways that [00:07:00] provide them with a potential wiggle out, um, of coverage. So one issue that we have seen repeatedly with residential treatment is insurance companies maintaining that they will not provide coverage for treatment.
in a residential facility unless they have a nurse on premises 24 hours a day. We were anxiously awaiting a court ruling on this issue because we had made an argument to a court that the language in the plan that we were litigating did not require that a nurse be physically present 24 hours a day, only that nursing services be available 24 hours a day, which clearly was in place at the facility.
Unfortunately, the judge found a flaw [00:08:00] in the underlying issue and ducked the question entirely. So, we're going to have to wait for another day to get a ruling on that particular issue. But, um, I, I think that, that the availability of coverage Has perversely, um, uh, led to more denials that are being challenged and being publicized because, um, uh, you know, before there just was no way to do anything about this.
Right.
Brenda: So you mentioned the Parity Act, um, that was put into place 15 years ago. Could you just, Give us a quick overview of what that is. I know that it entails a lot, but maybe just a summary of what that is.
Mark: Sure. I need to go further back in time because there was an earlier version of the Parity Act that Congress passed in the 1990s that was completely ineffective because it had [00:09:00] so many loopholes.
Because of the defects in the prior law, there were There were members of Congress who were influential and zealously devoted to the cause and were able to put together a significant revision of the earlier law that became the Mental Health Parity and Addiction Equity Act. It's also known as the Paul Poundstone Pete Domenici Act.
And, uh, you could not find two more polar opposites in the United States Senate. Uh, Paul Poundstone was probably, during his service in the Senate before his tragic death, probably the most liberal member of the Senate at the time. And P. T. Domenici was probably the most conservative member of the Senate at the time.
But they found common ground in understanding the need for the passage of this law. [00:10:00] Another major figure involved in the passage of the law was former Representative Patrick Kennedy, who was the son of Edward Kennedy, who was then in the U. S. Senate. And, um, Representative Kennedy, um, was extremely forceful in making sure that substance use disorders, uh, be included in this law.
His father was actually strongly opposed to that and felt that it was, A provision that could probably or that would likely kill the bill, but, uh, Representative Kennedy was so insistent, and he was able to bring, uh, Senator DiDomenici and others in line, and eventually we got the law passed, um, and Patrick Kennedy's no longer a member of the House of Representatives, but he created And, an organization called the Kennedy Forum [00:11:00] that is devoted to ensuring that patients who have mental health issues and are seeking insurance coverage.
Receive the parody in coverage that's promised by the mental health parody law.
Brenda: Okay, so it was supposed to create a even playing field Potentially, but it clearly did not
Mark: I mean it did and it didn't the language of the statute for certain says Yes, but the devil is always in the details
Brenda: right and insurance companies are very good at details so Maybe we could pull back a little bit and you could give us an idea when when a family comes to you What's the typical scenario?
So what are you seeing as sort of on repeat? You're getting these phone calls What are families dealing with
Mark: typically they've been denied benefits. They're not coming to us before they make a claim Because they have [00:12:00] every expectation that it's going to be covered And then they find out to their dismay that it's not.
Most people have their, um, insurance coverage through their workplace. And if they are, uh, employed by a private sector employer, their health benefits are governed by a federal law called the ERISA law. It's an acronym for the Employee Retirement Income Security Act. And one of the major features of ERISA with respect to benefit claims is that if there is a claim denial, the claimant has to be offered a full and fair review of that denial.
And the U. S. Department of Labor, which has jurisdiction over ERISA, has specified what that full and fair review consists of. So some of the key features are that the claimant It is [00:13:00] entitled to a complete copy of the insurance company's claim file free of charge. Another key feature is that your doctor can act as your representative.
You are allowed to be represented in these appeals, but it doesn't have to be by an attorney. Your doctor can be your representative or some other advocate can be your representative. There are time frames that are spelled out in the regulations. that give the claimants adequate time to muster an effective appeal and also, um, give the insurance companies a more, um, uh, narrow window in which to decide the claim appeal.
And then on top of that, we now have, thanks to the Affordable Care Act, When the appeals are exhausted, the claimants have the right to an independent external review. That's
Brenda: [00:14:00] pretty thorough, and I would guess the majority of people don't know that they have that right.
Mark: Unfortunately, that's correct. I've seen a statistic from the Kaiser Family Foundation that fewer than 2 percent of claim denials are appealed.
Wow. So the insurance company is, insurance companies are obviously well aware of that. And they are counting on few people actually. Trying to pursue their rights through the appeal process,
Brenda: right? It's sort of a game of odds.
Mark: Yes,
Brenda: exactly If there's only going to be 2 percent that's yeah, that's pretty good odds for them so what what I hear from our families and what I experienced as somebody who tried to fight a denial is that A couple of things.
One, there was not medical necessity, and I think with substance use, that's incredibly difficult because, yes, my kid's been in treatment for a month. He's no [00:15:00] longer, he no longer has the substances in his bloodstream, so. You know, at some level, somebody is saying, well, he doesn't need treatment anymore. He doesn't need this level of treatment.
And then also just the, the kind of treatment that is needed or the length of stay that is needed, especially when we talk about adolescence. So there's probably a lot of questions in there. Let's start with the medical necessity part of that. Is that something that you're finding? sort of lacking or that isn't being documented well enough?
Mark: It's an issue that we see persistently and the specific example you gave of somebody who is in treatment for a substance use disorder after they're detoxed, whether they need to have that level of supervision, you know, fortunately for claimants, um, the American Society of Addiction Medicine. It has guidelines [00:16:00] for treatment of substance use disorders.
And at least four states have mandated the use of those guidelines, they're called the ACM guidelines, American Society of Addiction Medicine, and they're recognized as guidelines that are the result of a consensus of expert medical opinion. Unfortunately, um, the insurance companies use their own guidelines.
The common, commonly used guidelines that we see are either the Milliman Care Guidelines or the Optum Guidelines. The guidelines are designed to discharge somebody from care. When their situation is no longer acute. So, for instance, um, somebody who goes into residential treatment for eating disorders, when they've gained [00:17:00] a few pounds in treatment, the insurance company says time's up, it's time to leave, when additional treatment is absolutely needed.
Or somebody who has either attempted suicide or has threatened suicide. You know, once the level, once their care is stabilized and the suicide risk is minimized, the insurance companies say it's time to leave when in fact it's not. Um, and what's really unfortunate is that A major court ruling called Witt v.
United Behavioral Health that was decided by a federal court in San Francisco was overturned by the U. S. Court of Appeals. Why that decision really stands out is because the decision began with a [00:18:00] number of different courts generally accepted standards of care in the treatment of behavioral health conditions.
And one of the critical standards that the court found following a trial, a 10 day bench trial, was that stabilizing the patient is not enough, that the treatment remains medically necessary in order to prevent destabilization, or a loss of the gains that have been made, or a relapse. That's the whole reason behind residential treatment.
is to, um, be able to, uh, have an extended period where not only can the gains be preserved but reinforced as the patient becomes more self aware and self accepting of what the problem [00:19:00] was so that they can be able to function back in their home environment. With the same stressors and pernicious influences that may have led them down the path in the first place, that they have a, a resistance mechanism built in.
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These four states, and we'll, I'll put in the show notes, what states those are. They're playing from the ASAM rule book. The [00:21:00] insurance companies are playing from a different rule book. And so it's no wonder we're having such a clash and this really, you know, pedestrian thought that I have is, but shouldn't we be looking at doctors to give us this?
I mean, are the Milliman and the Optum guidelines created by physicians or this is just astounding to me. I'm kind of speechless. Like what? Who's making these
Mark: decisions? So, these guidelines purport to be evidence based. But, um, again, going back to the WIT decision, the trial revealed that financial employees of UnitedHealthcare sat on the guidelines committees and were influential in the deliberations by the guidelines committees.[00:22:00]
Milliman is a international consulting organization. And they have financial incentives to save their clients money. I'm, I'm sure that there is some input, but the guidelines from organizations such as ASAM, or the um, the LOCUS guidelines, the Level of Care Utilization Service guidelines, or the Child and Adolescent guidelines, are developed by expert medical bodies who don't have those same financial incentives or potential conflicts that would influence their decision.
They're basing their guidelines on peer reviewed studies. of [00:23:00] evidence based treatment and how that treatment has worked or has not worked. So that if today's guideline turns out not to be appropriate treatment, that it will be revised and replaced with an appropriate guideline. And it's, it's very fluid.
I mean, you know, there, there are Tremendous changes in medicine almost by the minute, um, as far as the development of new drugs, new treatment modalities, um, research around the world has provided, uh, new insights into how to treat various mental health disorders. And, um, you know, while insurance companies take the position that it's not their responsibility to pay for experimental or investigational [00:24:00] treatment, you know, once a treatment becomes the standard of care that is generally accepted by the expert medical community, they should cover it.
Now, another hindrance that claimants face though is that the Supreme Court decided a case in 2003 called Black Decker Disability Plan vs. Nord. And what that case ruled was that insurance companies do not have to defer to the opinions of treating physicians. They can't ignore them. They have to address them.
But they don't have to defer to those opinions. And what the Nord case ended up creating is these vendor organizations that [00:25:00] have, uh, physicians who they work with who are writing these reports upholding the insurance company denials. And the courts are giving those reports as much weight. If not, sometimes more than the doctors and the nurses and the therapists who are actually treating the patient and dealing with their unique circumstances.
For self funded plans, and in a majority of the states, the courts will apply a standard of court review that's known as arbitrary and capricious or abuse of discretion. Which means that the insurance company is brought into court on a uneven playing field with the patient. Because the court starts out by putting a thumb [00:26:00] on the scale in favor of the insurance company and deferring to the insurance company's decision unless the claimant can prove that the decision was arbitrary and capricious.
A standard that comes very close to irrationality. That is a huge burden that claimants face in these cases and makes it much harder to be successful in the litigation. That really
Brenda: places the onus on the treatment providers to do studies or whatever they have to do to create a condition where that would be considered the standard of care.
Is that true?
Mark: Essentially, yes. The letter of medical necessity is critical in these cases because a letter of medical necessity that is going to be effective has to describe [00:27:00] why lower levels of care have been ineffective, provide the rationale for why this level of care is appropriate, and support that opinion with peer reviewed literature, consensus statements from authoritative medical bodies.
Another problem that patients have is that these guidelines are simply guidelines. They're not rules. And courts often confuse the distinction between the two. Because every patient is unique. You have some patients who have dual diagnoses. You have some patients who are younger, some who are older. They might have a comorbid physical illness that could be a factor.
That medical necessity determinations really require [00:28:00] looking at each individual patient. But ProPublica did a story a couple of months ago that talked about how, um, basically AI is being used to reject claims. And these claims are being denied in seconds, virtually without any human input. The reason that they can do that is because the AI.
We'll look at the claim and if there isn't an adequate medical of the letter of medical necessity They can spit that claim out immediately, but it really needs to be on on both sides it needs to be on the admitting side from the the the treating doctors and therapists who are recommending the admission and on the receiving side by the facility, the initial assessment has [00:29:00] to document the need for this level of treatment and why this level of treatment is necessary and can't be provided at a lower level of treatment.
Brenda: Right. That's fascinating about the AI and I remember you telling me earlier about some work that's being done to use AI for good in this case, which is it would help physicians and therapists right Very tight letters of medical necessity. Is that it's that still ongoing?
Mark: It is ongoing. I've been in touch with one Provider that's trying to establish this.
I'm sure there are others out there. That's
Brenda: very exciting. I'm glad to hear that There is some good news. So That's uh, it kind of leads me into thinking about scenarios where you know families are sending their kids to Wilderness therapy, residential treatment, and only getting. And, and my [00:30:00] question is if this is just what we should expect.
They're only getting coverage for maybe the one hour of therapy that that young person is getting while they're in wilderness or while they're in residential. Is that pretty typical or is, can you get more than that?
Mark: You can get more than that. Under the mental health parity law, the coverage for mental health treatment is supposed to be in parity with coverage for physical treatment.
So, let's say somebody has had a hip replacement. They're discharged from the hospital a day or two after the surgery, but they're not discharged home. They're discharged to a rehabilitation facility where they can receive intensive physical therapy, and the insurance companies cover The residential component of that.
So they should be [00:31:00] covering the residential component of the, um, residential treatment as well, because a significant aspect of residential treatment is the need for 24 hour supervision. Correct. So if you're, if you're not, if you're only covering the actual time spent in psychotherapy, you are not covering.
All of the treatment that is medically necessary.
Brenda: Okay, that makes sense. And, and so that is, I think, something for parents who are listening to not just expect, because I think there is sort of a level of expectation, um, among a lot of people that, well, that's all you're going to get covered. So thank you for clarifying that.
If a family is listening and they're considering So child's still at home. And when I say child could be, you know, into their mid twenties, are there things that they could do [00:32:00] ahead of time to set themselves up for the best possible, um, claim situation? Just, and I know that's really hard to do when you're in the moment, because your brain is already, you know, scattered and you're, you're doing so many things.
But if they were able to, is there anything that a family could do heading into this process that would set them up for the best possible chance of coverage?
Mark: I think that they should start the discussion with the treating doctors as early as possible. So that they're comfortable that the treating doctor, the educational, uh, consultant, um, the therapist are all on the same page and they're prepared to put together a robust letter of medical necessity.
You know, oftentimes they, they sort of have these things in the can already and they just need to modify them for each patient. But, um, the worst thing that can [00:33:00] happen is to just get a state, you know, a conclusory statement. It's my recommendation that the patient should be in residential treatment.
That's all fine and good, but that doesn't win the day if the insurance company is going to push back. They have to say, it's my recommendation because. And that discussion should be had from the outset. Any parent who is dealing with a child who is experiencing these issues and is not getting better, And, um, lower levels of treatment should be anticipating that this might be where this is headed and should be prepared for the likelihood of a denial by the insurance company so that they need to be thinking about how can we head this off.
[00:34:00] And you're always better being proactive. And having that great letter of medical necessity going into the claim, going into a facility, then trying to create one afterward. Because it just doesn't have the same level of credibility. It looks like it was created for the purpose of justifying a decision that was already made.
And the insurers are likely to discount
Brenda: it. And is it important to have a paper trail? I just remember going through this. I had a binder that was about two inches thick of all of the different school issues. Police issues, you know, times he'd been arrested, um, times he had been in the hospital beat up by a drug dealer.
Does all of that go into it as well? Like, should we be keeping that paper trail to use for that letter?
Mark: Absolutely. You want to bury the insurance company in paper? Okay. To show [00:35:00] exactly what's been going on, how long it's been going on, that, you know, I read, I read all the cases and the ones that are the winners are the ones with the extensive paper trail because, I mean, can you imagine a judge getting one of these cases and seeing, you know, somebody started psychiatric care when they were 10 years old and They had their first psychiatric hospitalization when they were 11 and had law enforcement involvement, school suspensions.
It just has to make the judge more sympathetic. Well, and
Brenda: it just builds the case. Like you said, you've got to have that story to tell and I think it's really important for parents to remember that because when you're in it, you're so overwhelmed and you probably forgot about that assessment that you [00:36:00] had when they were 10 or when they were diagnosed ADHD in third grade or whatever it is.
So I know some insurance companies have sort of this liaison that will work with parents as they're in this. Um, we, we got a call after my son's last overdose where they offered to help us. I feel like that's a little bit like playing with the enemy. Is there Is there anybody to help parents walk through this before they have to get to filing a lawsuit, before they have to get to litigation?
Is there a way to have somebody guiding you to make sure that you're doing this at least as well as you can?
Mark: Uh, the educational consultants should be up to speed on these issues. Okay. And they should be your primary point person to coordinate what kind of documentation you should start pulling before the admission and what you're going to need after and help coordinate the letter of [00:37:00] medical necessity.
They're sort of in the middle and they, um, they have a 360 degree perspective on what's going on. Okay, that's
Brenda: a great, great tip. And if you're not working with an educational consultant, then those are things that you're going to need to be gathering yourself. Is there anything else, like, I get so fired up when I hear this because it just seems so, there's just so many parts of it that seem wrong, but my case is, you know, nine years old.
Is there anything that families or parents can do to kind of advocate in this space? You know, we're not lobbyists or anything like that, but is there anything that we can do to start to make some noise in this situation?
Mark: Parents should be advocates for their children. And they should be looking for media opportunities.
They should be talking to their state representatives and state senators, um, or even their [00:38:00] governor, as well as their congressmen and senators. Because the more noise you can make, um, the likelier it is that the problem is either not going to happen or it's going to get fixed. The media should be more receptive to this because they are, these are clearly human interest stories and most television stations have a, you know, investigation feature that they do and how they help people get results.
I mean, they can't do one of these stories every single week, but, um, they're the kind of stories that they're looking for. NPR does a weekly, you know, Medical Bill of the Week story. You know, Kaiser Family Foundation, ProPublica, they're always doing stories on this. People are afraid to talk to their, um, their representatives in their [00:39:00] states and their congressional representatives because they feel that They don't know me.
You know, I don't even know who my representative is. I don't know who my congressman is. Um, but the reality is that your political representatives are interested in your story. When you call up a state representative's office or a congressman's office and say, I'm in favor of this bill or I'm opposed to that bill, they just make a little tick mark and they keep track of that.
When you call up and say, can you help me with this issue? You know, I'm getting nowhere. With the Department of Insurance, you know, my, my child is in a desperate situation. I, I, I can't fight the insurance company by myself. Is there anything you can do to help? If you have a good representative, they're going to be eager to do that.
[00:40:00] Because what happens is, that adds up to a lot of votes in November. People will see their neighbor when they're taking out their garbage and they'll say, Hey, you know. Have you ever talked to Representative Smith? And they'll go, no, no. Who's Representative Smith? Well, he's our representative. In, I'm in Illinois, in Springfield.
Um, and they'll say, you wouldn't believe it. I, I, I didn't even vote for the guy. I never gave him a, a contribution when he was running for office. But I called his office and his office staff just sprang into action. And he personally took an interest in my, in my situation and, and helped out. And then that neighbor's thinking, wow, you know, it's a pretty good representative and it gets around the neighborhood and it adds up.
And that's why politicians are eager to get good ones. Are eager to get involved in it. There are [00:41:00] plenty of politicians who are not so good and they don't really care about those issues But my experience is that the majority of them do care and the majority of them Take very seriously that they are public servants and that means they need to serve the public
Brenda: Yeah, good.
Good press can go a long way and my last questions I know I need to let you go is what other recourse do you have? So if you have fought your claim with your insurance company, repeatedly denied, denied, denied. What are sort of the next steps or maybe this is something you are, you probably already have this on your website, but what are the, some of the next steps that a family could take to say, no, we're not going to accept that.
We're going to take this, like what's the recourse, what's the chain of command
Mark: there? Claimants should try to get an attorney involved in the appeal process. And the reason for that is that [00:42:00] for a lot of these cases, if they do end up in court, the attorney may have his or her hands tied behind their back as far as admitting additional evidence.
So, an experienced attorney who has expertise in this area can compile a stronger record. so that either the appeal is going to be successful or there's a greater likelihood of succeeding in court. There are also organizations across the country that provide assistance with claim appeals. They should be looked at as well.
Um, you know, I know fees can vary. In some instances, people would be surprised to learn that An attorney's fees are less than a non attorney, uh, representative or claim advocate would charge. Interesting. I'm not saying that [00:43:00] that's universal. Right. Because unfortunately, uh, you know, people have heard of contingency fees.
And contingency fees have been described as the key to the courthouse door for people who don't have the financial resources to hire a lawyer to fight for them. But contingency fees are only viable if you are recovering a sum of money from another party. With these insurance cases, You're just trying to get them to pay the doctor, pay the facility.
So they're, they're generally not amenable to contingency fee represented, representation. Although they could be if the patient has paid out of pocket and is trying to get reimbursement from the insurance company. But that's a case [00:44:00] by case determination. But it, it is really important to have somebody who is knowledgeable and experienced to assist in this process.
Um, this is complicated. You are dealing with a insurance company that has a very high level of sophistication. And they're often quite determined to uphold that denial. I do believe that they want to see valid claims paid. And they want to see invalid claims denied. But sometimes that can be a little bit of a shady area.
And, you know, I'm not suggesting that insurance companies are evil and that they're going to put up, always going to put up roadblocks in front of patients. Sometimes what we found with these cases is that there's just a misunderstanding. Or there is a piece [00:45:00] of evidence that they're looking for that they didn't adequately describe so the patient didn't get it.
Or, I mean, there could be a host of things. You know, the facility could have faxed in records and the intake assessment somehow didn't make it into the fax. And that's why the claim was denied. And getting that document can make all the difference. But getting somebody on the scene who can help? Because, as you mentioned, you know, you're in the moment.
You're, you're dealing with a child in crisis. You don't have time to deal with this on your own and you're not necessarily going to make the best decisions. Correct. So, get somebody involved to help as soon as possible. Absolutely. And, if the appeals are unsuccessful, That's what the courts are there for.
Brenda: You do have rights, and that's, I'm so glad you described ERISA because I, I do think that that's something that everybody needs to know [00:46:00] about, so. Thank you so much, this is incredibly helpful. If you're listening, we'll put links to all this information in the show notes. How you can get a hold of Mark's firm and, uh, just be an advocate, I guess that's what I would say.
Any, any parting words for a family in the, in the thick of it?
Mark: Don't let them wear you down. Keep fighting.
Brenda: Perfect. Thank you, Mark. I appreciate it so much. Thanks. Okay, my friend, that is it for today. Remember, you can find all the guest information and resources we talked about in the show notes and those are at brendazane.
com forward slash podcast. We also have some playlists there that we created for you, like the top 10 episodes, coaching episodes, recovery stories, all the good stuff. And if you haven't already, you may want to download a free ebook I wrote called Hindsight, Three Things I Wish I Knew When My Son Was Misusing Drugs.
It'll give you [00:47:00] some insight as to why your child might be doing what they are, and importantly, it gives you tips on how to cope and how to be more healthy through the rough times. You can download that free from brendazane. com forward slash hindsight. Thank you so much for listening. Stay strong and be very, very good to yourself.
And I will meet you right back here next week.