In December 2023, Mark DeBofsky appeared on the Hopestream Community podcast in an episode titled, “Exposing the Hard Truths: Insurance Claims Denials for Substance Use Treatment.” This insightful discussion highlights the numerous challenges families encounter when seeking insurance coverage for substance use treatment.
Key Points Discussed:
- Mental Health Parity and Addiction Equity Act: The episode covers the ongoing struggles families face despite this act’s goal of ensuring equal coverage for mental health and substance use disorder treatments.
- ERISA Law: Mark explains that the Employee Retirement Income Security Act (ERISA) governs most health benefits in the private sector. ERISA ensures a full and fair review of denied claims, allowing claimants access to the insurance company’s claim file and the opportunity to have a doctor or representative assist during the appeals process.
- Low Appeal Rates: Less than 2% of denied claims are appealed, often due to a lack of awareness among claimants about their rights and the challenges of the appeals process.
- Use of AI in Claims Processing: The use of AI by insurance companies to support or deny claims raises concerns about fairness and transparency, despite its potential to streamline processes.
- Advice for Families: DeBofsky emphasizes the importance of thorough documentation and early action when dealing with insurance claims. He advises families to understand their rights and be proactive in seeking coverage for medically necessary treatments.
- Wilderness Therapy Ruling: Mark also discusses a significant ruling on wilderness therapy that may deter broad policy exclusions. This ruling highlights the need for insurance companies to follow the terms of their policies without imposing unreasonable exclusions. More details can be found in the article here.
This episode provides valuable insights and practical advice for navigating the often frustrating landscape of insurance claims for substance use treatment.
Listen to the Episode
For more details and to gain a deeper understanding of these issues, we encourage you to listen to the episode here.
Stay informed and empowered by understanding your rights and the intricacies of the insurance claims process.
