116 3rd St SE
Cedar Rapids, Iowa 52401
Ever since she was 13, Mindy Pfab, now 28, carried the burden of anorexia nervosa. She coped with the eating disorder for years through outpatient treatment and seemed stable.
'Then it just took a nose dive,' said Pfab, of Cedar Rapids.
She decided she wanted to shake loose the disorder that had overshadowed more than half her life, perhaps with more aggressive treatment. Last year she heard about a possible answer — The Emily Program in Minneapolis.
Within days, she was in contact with the center, and it in turn with her insurer. For part of last spring, Pfab drove from Des Moines, where she lived and worked at the time, to Minneapolis at least three days a week for the intensive treatment from the center. She grew physically and mentally healthier. It seemed a success.
Until she opened her mail one day and found a nearly $50,000 surprise from Wellmark Blue Cross Blue Shield.
CHOICES MORE LIMITED
There are an estimated 101,480 Iowans with an eating disorder, according to the Eating Disorder Coalition of Iowa. But choices for those seeking intensive therapy are limited.
The University of Iowa's Eating Disorder Treatment Center is the only inpatient treatment center in Iowa,
The Emily Program in Minneapolis serves about 6,000 patients annually through intensive outpatient and residential treatment programs.
But since last fall, after facing insurance billing issues like Pfab's, the center stopped accepting Wellmark beneficiaries.
Jillian Lampert, chief strategy officer for the center, said 'a handful' of patients have been turned away since the decision, but it's impossible to determine the number of people not seeking treatment.
'Added to the difficulty of leaving the state to get treatment is the difficulty of whether or not insurance will be an issue,' she said.
Although it has long been challenging to obtain insurance coverage for eating disorder treatments, experts say, it was never this difficult, Lampert said.
'In June of 2015, something seemed to change,' she said. 'We don't know what it was. This theme is significantly concerning and different from our typical experience with Wellmark. People can die from these illnesses. We have told patients who call with Wellmark that despite the fact they hear ... that their services will be covered, we in good faith cannot admit them to our program any longer. We do not want to put them in that financial position.'
Teresa Roof, a Wellmark spokeswoman, said the Mental Health Parity and Addiction Equity Act of 2008 requires insurers to 'equalize the level of coverage of mental health services with those of other medical conditions.'
As such, Wellmark treats the authorization and coverage of mental health treatments the same way it would for residential treatment programs for other medical needs, Roof said.
'When services are pre-authorized, those services need to be completed in order to be covered,' Roof said. 'Wellmark requires pre-authorization to validate the level of care is appropriate and medically necessary. In some cases, we receive requests for provider reimbursement for a level of care that the medical records do not support. In those cases, coverage may apply for some services and not to others.'
Wellmark since has agreed to cover some additional costs of Pfab's treatment, but with tens of thousands of dollars still at stake, the dispute continues.
When Pfab first sought treatment at The Emily Program, the center checked with her insurer. It learned she would require pre-authorization for residential treatment, one of the highest levels of care that includes staying at the center around the clock.
After an initial assessment, residential treatment at the center indeed was recommended to Pfab. But Pfab opted instead for intensive outpatient treatment — the lowest level offered there and one step above outpatient treatment.
Pfab wanted to continue working, and had called Wellmark herself to see if that was included under her plan.
'It was worth (seeking therapy) to be in a better place of recovery,' Pfab said. 'But this is overwhelming. I've got other issues going on. I don't know that I would have sought treatment if I would've known it wouldn't be covered. I would have benefitted from going to treatment for years.'
In looking at her claims after receiving the denial from Wellmark in late spring 2016, Pfab said she could not understand why some days of treatment were authorized but others denied,
Pfab began an internal appeal with Wellmark.
In August 2016, after Pfab had moved from Des Moines to Cedar Rapids, Wellmark claims processors continued to ask for documentation.
Pfab said she wasn't sure which documents were the key to proving her treatment was necessary, so she mailed in all 1,671 of them.
In January, Wellmark notified Pfab her internal appeal was denied.
According to a letter Wellmark sent to Pfab, and reviewed by The Gazette, her medical records 'support the level of services billed' for specific days when Pfab began therapy. The insurer would pay for the first 20 days — about $15,000 — but not others.
'Although you were being treated for symptoms of chronic food restriction and excessive exercise, there was no evidence of severe problems with social isolation, agitation or interpersonal conflict and you were medically stable and able to do your activities of daily living,' the letter read.
But the letter left Pfab even more confused.
'They specifically noted they didn't pay for the assessment, which is what told me I needed the treatment they then paid for,' Pfab said.
OTHERS DENIED ALSO
After exhausting the internal appeals process, Pfab was one of four Wellmark of Iowa beneficiaries who contacted Elizabeth Wrobel, a Minnesota lawyer who specializes in mental health and eating disorder cases.
Wrobel's other clients sought residential treatment at The Emily Program and received pre-authorization through Wellmark, she said. But then after they left the program, payments were denied. Wrobel said.
'I have never seen a situation where an insurance company denied the medical claims after pre-authorizing the treatment, especially when clinical information was provided,' Wrobel said.
Pfab did not seek the residential treatment as the other clients had, but nonetheless Wrobel said she had never seen a case similar to hers — where the insurer covered some days but denied the overall claim.
Pfab and the other three clients are now working with Wrobel on another appeal process.
Lampert said she hopes The Emily Program someday will be able to work in the future with Wellmark, one of the biggest insurers of Iowans.
'We're really hopeful this situation resolves,' she said. 'We would like to provide care for people on Wellmark in Iowa, and this is standing in their way.'
l Comments: (319) 368-8516; email@example.com