July 21, 2025 • 39 mins
The fight for adequate mental health coverage can feel overwhelming, especially when insurance companies deny care that clinicians deem necessary. Joe Feldman turned his personal battle into a mission when his child's residential treatment was denied coverage through fabricated documentation. After winning a federal lawsuit, he created Cover My Mental Health to help others navigate the same challenging landscape.
At the heart of Feldman's approach is understanding the critical disconnect between what insurance companies call "medically necessary" and what clinicians know as "generally accepted standards." This gap allows insurers to deny appropriate care while claiming to follow policy guidelines. Through Cover My Mental Health, Feldman provides powerful resources that help bridge this divide by empowering clinicians to document their expertise and treatment decisions effectively.
The podcast explores broader issues in mental health coverage, including the troubling difference between physical health treatment (covered through recovery) and mental health care (often only covered through stabilization). Feldman challenges the economic arguments against comprehensive coverage, noting how some industries have already recognized the value of fully funding treatment programs and seeing remarkable outcomes.
Ready to advocate for better mental health coverage? Visit covermymentalhealth.org for free resources, templates, and tools designed to help you overcome insurance obstacles and access the care you or your loved ones deserve. Together, we can push for a system that values recovery, not just crisis stabilization.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Todd Weatherly (00:01):
Hello folks, thanks for joining us on Head
Inside Mental Health, featuringconversations about mental
health and substance usetreatment with experts,
advocates, professionals fromacross the country sharing their
thoughts and insights on theworld of behavioral health care.
Broadcasting on WPBM 1037, theVoice of National, I'm Todd
Weatherly, your host,therapeutic consultant and
behavioral health expert, andwith me today is Joe Feldman.
(00:25):
Joe is the president andfounder of Cover my Mental
Health.
Joe has been advocating foraccess to mental health care
after overcoming denials for hisadolescence residential care,
including with a successfulfederal lawsuit.
Joe established Cover my MentalHealth based on his own success
overcoming insurance obstacleswith input from leading
(00:45):
legislators, appeals experts,clinicians, insurance regulators
and former insurance industryinsiders.
Cover my Mental Health'sresources have been presented to
advocacy organizations inIllinois, georgia Tech, maryland
, connecticut and New York.
To clinical organizations,including UT Health in Houston,
westman Dunstan organizations,including UT Health in Houston,
who plays with us and does workout there with Lindner Lindner
(01:06):
as well Lindner Center of Hope,menagerie Clinic, silver Hill
Hospital, norton Healthcare.
To clinical conferences hostedby American Psychiatric
Association and the NationalCouncil for Mental Well-Being,
as well as what was the lastconference you just did, joe.
Joe Feldman (01:21):
The International OCD Foundation Conference in
Chicago.
Todd Weatherly (01:27):
That was great Covered by Mental Health has
been featured in numerousclinical and mainstream
publications, as well as ontelevision news in Cincinnati,
philadelphia and Michigan.
Joe's advocacy work hasincluded policy-driven
discussions with legislators andregulators, board role with
Kennedy Forum in Illinois,presentations to parent groups
and publication of actionableguides, such as a 2021 article
(01:50):
in the Journal of PsychiatricPractice on Medical Necessity
Letters.
Joe also serves on the board ofThresholds, a Chicago-based
firm that I support to thislevel of meaning, joe welcome to
the show.
Joe Feldman (02:05):
Thanks for having me.
That's a big introduction.
I'm going to have a tough timefilling the bill, but I'll do my
best.
Todd Weatherly (02:14):
Well, you know I'll give you a chance to live
up to it.
I have no doubt we've got alittle something in there.
You and I have gotten to talkprior to now, a little bit
through some mutual connectionswho have been running the same
circles, fighting the powersthat be for insurance coverage
and just getting to acknowledgewhat actual residential mental
(02:35):
health care should look like.
It's not seven or 12 days, youknow.
It doesn't come just fromhospitals and you are not alone.
It doesn't come just fromhospitals and you are not alone.
And this fight is far from overin terms of, you know, getting
insurance companies to recognizewhat good care is, pay for it,
understand the benefits of justpaying for good care instead of
ramming people into thisshort-term model.
(02:57):
What's the latest?
You know what's the latestsuccess that you feel like
you've achieved so far in kindof being in this fight after
you've started to come out ofthe lab.
Joe Feldman (03:10):
Well, so we have been around since the very
beginning of last year and ourwebsite's been up since May of
2024.
And we're starting,step-by-step, to hear success
stories of folks who've used ourresources to overcome insurance
obstacles.
And I can share maybe two ofthose success stories with you,
(03:30):
and this is, I'll say, reallythe goal of what we're trying to
do.
So one was from a clinicianhere in Northeastern Illinois so
I live in suburban Chicago andI had had a conversation with
this particular clinician whoworks in addiction medicine, and
we were talking about thepossibility of my coming to her
(03:52):
hospital and giving a talk aboutour resources to her and her
team.
And a couple of weeks afterthat she reached out to me and
she said I just want to let youknow that I had an occasion
where an insurance company wasstanding in the way of my
prescribing a particularmedication to one of my patients
and I was getting frustratedbecause this was sort of all too
(04:17):
familiar to me and I knewexactly from my training and
experience and from working withthis particular patient that
this med was the right choice.
It was the standard of care andI thought I'm going to go to
that website and see if I canuse the template for a medical
(04:38):
necessity letter.
And she said she used ourtemplate.
She said she used our template.
She of course adapted it to theparticular needs of her patient
.
She included the specificobjections that the insurance
(04:58):
company had put between herpatient and the necessary care.
She submitted that letter tothe insurance company and they
said we approve the delivery ofthat medication.
I was of course, thrilled, soit was.
You know.
That's I'll say.
You know, in a way, that's theway it should work.
I mean, the way it reallyshould work is the clinician
(05:19):
should have the prerogative toprovide the right medication.
But in terms of overcoming theobstacles, it was a great
example.
Todd Weatherly (05:29):
If you will, before you go into the second
example, what are the parametersin this letter, this form that
you've created, that you thinkmakes the difference?
Joe Feldman (05:40):
So a medical necessity letter is a I'll say a
tool that clinicians can use todocument who they are and the
decision making and the way Ilike to describe the template
which you can download on ourwebsite it's in Word, by the way
, so it's very easy to adapt andsort of get customized for any
(06:06):
particular use.
The way I like to describe itis it's like a conversation that
you can imagine between aclinician and the insurance
company, where the conversationgoes something like this Let me
introduce myself to you.
I was trained at the followingmedical school or the following
(06:27):
clinician program.
Let me tell you about mypractice area and my experience
there.
Let me tell you about thisparticular patient, the
relationship that we have, andwhat I've determined is the
diagnosis that we're working onin support of this patient's
recovery.
These are the generallyaccepted standards that I have
(06:50):
found applicable in thisparticular case, that guide me
to make this clinical decision.
These are some risks that I'vethought about if the patient
didn't get this care or wasasked to have care at a
different level or with adifferent med, and so, in
conclusion, this is the carethat is appropriate for this
(07:12):
patient of mine and signed bythe clinician, and so it's a
very it's very common sense sortof conversation.
It's in writing.
It includes language that wasdeveloped with input from some
of the folks that you mentionedin your kind introduction folks
(07:33):
who are litigators in this area,regulatory experts, former
insurance company executives andthe instructions that are part
of this template provide promptsand suggestions, which, of
course, a clinician can eitheruse or not use, at their
discretion, about specificlanguage that might be helpful
(07:55):
to them.
And I'll say it's ascommonsensical as that.
We're not trying to turnclinicians into lawyers.
Sensical as that.
We're not trying to turnclinicians into lawyers.
We're trying to give cliniciansan opportunity to document what
they're good at, which isapplying their training and
(08:16):
generally accepted standards toclinical care.
Todd Weatherly (08:19):
Well, and I assume, having seen, you know,
not that many necessarily ofthese the ones that I have seen
are like it's a doctor's order,for maybe it's a better
procedure or what have you, andnone of that stuff's there.
It's like this person has thisdiagnosis, we're prescribing
this treatment.
It's pretty spark as medicalrecords go.
(08:43):
What you've done is bring inall the details I've got this
training these are the acceptedparameters for this treatment,
these protocols that we see here, you know industry standard, et
cetera, et cetera, and you'velined it all up so that the
insurance company can't sitthere and basically poke holes
in something because they'vealready stated everything.
That might be the dyingquestion, which is, I mean, you
(09:07):
know, sounds really simple, butalso brilliant, right?
Joe Feldman (09:10):
You know what I think that's exactly the right
characterization.
It's brilliant in itssimplicity and I'd certainly
like to tell you that it was myidea, but it's a concept that's
been around for a long time.
What we've done is we'vebrought together really the best
available thinking about this.
We continue to evolve it.
(09:31):
I think one question that folkshave when I talk about medical
necessity letters is sort of whyare we even having this
conversation?
And one of my, I'll say,clinical experts who I go to for
questions about this is AndrewGerber, who runs Silver Hill
(09:53):
Hospital in Connecticut.
Very just, pragmatic approach,and the way he described it to
me was so straightforward.
He said this.
He said if you look in thehealth insurance policy, what it
will say is we pay formedically necessary care.
(10:16):
That's the, I'll say, the coredeterminant of whether they're
going to pay for something ornot.
And he said clinicians don'tever get trained in medical
necessity.
It's a legal term.
The clinical terms that arefamiliar to clinicians from
their training are theHippocratic Oath, do no harm to
(10:38):
the 2,500-year-old.
You know sort of I'll say,familiar in.
You know, I'll say commonculture and safe and effective,
which is a phrase we think aboutcertainly when we go to the
pharmacy and we getover-the-counter meds, we look
for products that are safe andeffective and then generally
(10:59):
accepted standards and whatAndrew said is generally
accepted standards are thebenchmark that clinicians use.
And so when you have a legalterm medical necessity on the
one side and generally acceptedstandards on the other, you've
got two different measurementtools.
It's quite possible that thosetwo measurement tools are going
(11:21):
to come up with two differentanswers.
Those two measurement tools aregoing to come up with two
different answers, and the goalof a medical necessity letter
you could think of as taking allthe air out from between those
two standards and imposingmedical necessity determinations
be based on generally acceptedstandards.
Todd Weatherly (11:40):
Let's play with this a little bit and we might
actually go back to some of yourstory.
But I was with Dr Gerberrecently and I had the chance to
ask him this question Doinsurance companies provide
coverage?
It's also for long enough.
There are treatment periodsthat insurance companies observe
(12:03):
and then there are treatmentperiods that treatment
professionals observe, and thosetwo worlds kind of far and wide
and differ quite significantly.
I asked Dr Gerber this question.
Joe Feldman (12:14):
I said if they just went ahead and paid for it.
Todd Weatherly (12:19):
you know, the argument is that no subscriber
lasts more than what 18 monthsor something like that.
So you know, even if they payfor long-term treatment you've
got a long-term treatment formental health, for a mental
health condition they pay moretreatment for 18 months Well,
they're losing subscribers thatlong and you know they're not
(12:39):
seeing the benefit of a healthyindividual, of course, just
moving on.
So that's the art.
I said yeah, but cumulativelyeverybody.
If you start paying for it, onemight get more allegiance from
subscribers.
But, more importantly, youstart creating something in the
field where people are gettingtreatment and they're getting
(13:02):
better, and even the subscriberthat needs you goes somewhere
else, but their subscriber leftthem and comes to you with the
same benefits.
If the industry saw it that way.
Now Dr Gerber said they'll neverdo that because it doesn't
really apply, it doesn't workthat way and everything else.
I mean he's a smart guy.
He had what I might view as alegitimate answer and I'm like
(13:27):
well, they might have to bite itfor a year, you know, or
possibly two.
I think the insurance companiescan afford it.
What is your thought about thisin terms of the insurance
accuracy and what we want themto do?
Do you see it being a viablething to ask insurance companies
hey, why don't we present amodel to you where you pay for
(13:47):
the whole thing?
Or do you think there's a biguphill fight for it?
What is your experience of that?
Joe Feldman (13:54):
So there's, I'll say, two different ways of
thinking or two differentconsiderations here.
One is paying for care that isrequired, that it's appropriate
to someone who is sick, and sowe know, when it comes to
diabetes care or cancer care orcardiovascular care, insurance
(14:19):
companies pay for that care allthe time, and so is there an
economic basis for paying forsomeone's heart transplant or
cholesterol medication?
I would say the answer is Idon't know.
We should take a look at that,and there are certainly studies
(14:39):
that would suggest that earliercare results in savings down the
road from higher levels of careor even inpatient requirements.
Same for mental health andsubstance use disorder.
So the idea of you've paid forcoverage and we should expect to
(14:59):
get that coverage, I thinkthat's one level in which mental
health can be treateddifferently and really, I'll say
, unfairly and arguably possiblyillegally.
The question you raised aboutthe economics is really an
interesting one.
Description is the one Isubscribe to, which is I don't
(15:24):
believe that insurance companiesor, by the way, large employers
who have self-funded planswhere they are the economic
backstop for other claims theyhire a company that looks like
an insurance company to us butit's actually just an
(15:45):
administrator of thecorporation's plan and they tell
them how many claims are paidevery month and the corporation
pays for that.
And I've heard many companies'executives say to me you know,
if we pay for care and thensomebody leaves, we're not going
to get the benefit.
So I'm a hundred percent withyou.
(16:06):
That's a say, a simplistic viewof the world, because the
employees who benefit might staywith you longer as an employee
or as a member of your insuranceplan, and if more and more
companies insurance companiesact this way, then the healthier
(16:30):
employees who had the earlyinvestment are going to find a
new home and they're going to bethe healthier, lower-risk
individuals who show up and youget the free ride.
So this is, I think, a really Idon't want to pay for somebody
(16:52):
else's gain later.
I think it's a very weakargument.
Todd Weatherly (16:56):
Right, well, and you know there's.
We have a program not far fromhere.
They have a pretty largeprofessionals program Blue
collar folks, nurses, airplanepilots and train operators,
specifically the train industryand, I believe, certain
(17:19):
companies that have plane pilots.
They have decided to just goahead and pay for it.
Right, they decided to go aheadand pay for residential
treatment, step down to PHP andthen IOP and even six months of
sober living all the way through, whether it's covered by the
(17:42):
insurance or not, because whatthey found one employee
retention for some of these isreally, really important,
especially for the trainindustry, apparently, somebody
who's experienced at doing thatwork and has years under their
belt.
They can't just lose thatposition because they've got any
(18:03):
patients.
They're paying for the wholething and the result they see is
that they come back better whenthey come back ready.
Then they come back grateful.
The outcomes are so much betterfor these individuals.
It's hard for me to believethat insurance companies don't
(18:25):
see these examples and startpicking them up.
Yeah.
Joe Feldman (18:33):
So I'll tell you two stories.
So one is one of my keyadvisors used to work in three
different insurance companiesrunning behavioral health units
different insurance companiesrunning behavioral health units
and he told me that in each ofthese organizations, as he was
getting his I'll say getting histeam together and beginning to
work together, he found that theprior authorization
(18:55):
requirements and other, I'll say, friction in the system that
was built in to slow down, ifnot deny, care was, I'll say,
standard operating procedure.
And each time he said why arewe doing this?
We're standing in the way ofour saving money and providing
better care.
And they said, well, we reallyneed to hit our percentage of
(19:20):
reviews.
And he said, ok, well, we havea different standard now.
Instead of whatever thepercentage of denials or delays
have been, I'll say the targetspoken or I'll say documented or
undocumented, he said we'regoing to go down to the next to
nothing and he said, in eachcase, they made more money, he
(19:42):
said, and people were like, ohmy gosh, that was interesting.
And he said actually, no, it'snot, it's just logical.
We're seeing it actually inaction and I think that's an
experience that would be borneout if it were applied more
(20:02):
broadly, um, the other story Iwas going to tell you is I was I
made a presentation, um aboutsix months ago, to a group of
industry uh, insurance and um,um actuary and policy folks
about the cover, my mentalhealthorg website and our
(20:22):
resources and so on.
And a couple of people who werepart of that webinar contacted
me one just after the programand one had asked a question
during the program and thesentiment that they expressed
was you know, insurancecompanies kind of get a bad rap
(20:45):
for denying care, and all thathe said.
You know, we get requests fromour customers, large
corporations, who are asking usto administer their programs,
and they tell us we want lowerfees this year, we want lower
premiums this year and thereforewe have to find a way to do
that if we want to compete forthe business.
(21:06):
And so we're doing what we'retold to do, and I thought that's
not a good steady statesolution.
Not a good steady statesolution that's being, I'll say,
(21:26):
responsive to what the customerasked for, but not what the
customer wants or needs.
What the customer wants is ahealthier workforce with overall
lower cost of care, and so itbecomes a problem when the I'll
say answer is well, we're justgoing to tighten down on care.
(21:48):
One of the other factors thatis, I think, completely relevant
here is that specialtybehavioral health programs exist
within many insurance I'll sayprograms where the
medical-surgical side is handledby one organization and the
(22:09):
behavioral health is handled byanother organization.
They can be, by the way, ownedby the same parent corporation
not necessarily, but they can beand so you have these two silos
and each one has its own incomestatement that they're looking
to manage.
Todd Weatherly (22:26):
And never the same.
Joe Feldman (22:29):
Well, let's not look broadly at what the overall
implication is for thecorporation whose plan is being
administered or the families whoare being covered.
Let's look at our narrow P&L,our profit and loss statement,
and say what do we have here?
I guess we need to spend lessthis year, and so it's just
(22:53):
unfortunate that some of thereally great analysis that's
been done by leading consultingfirms and nonprofits and
governmental organizations thatpoint to some of these potential
benefits you know, is notpersuasive yet to the folks who
(23:13):
would make it real.
Todd Weatherly (23:16):
Well, we also don't have a comparative model,
because I think the same is true.
You know, one of the thingsthat I think is a is across the
street, if you will.
Uh, though connected intimatelyto the problem that we're
talking about, which is you'vegot hospital care and you've got
outpatient care and you've gottherapists and other other.
(23:39):
You know community-basedresources for therapeutic and
mental health care and wellness.
They don't really know aboutthis specialized behavioral
health, residential treatmentand step-down and all those here
kind of side effects and what Ifind, especially in community
(23:59):
mental health resources.
What I find is they don't knowabout it.
They don't know that it exists.
They've never seen the modelsthat actually work.
They've never seen realresidential treatment.
They've never really seen whata real ACT team should do take a
PHP, delivery and schedule andpsycho-ed and all these other
(24:25):
pieces and make it interestingand make it not just a recycled
version of the last thing theydid for everybody else, and so
they just keep doing the same.
You know they only know whatthey've seen right and you know
you get a psychiatrist who triesto prescribe meds and it's like
well, you know, this person isgoing to be facing this
condition.
You hear horror stories aboutwhat trained professionals
(24:47):
doctorate level professionalsare telling people about their
care and what's possible,because they never leave their
yard, and I think they don'thave an example, though for them
an example exists.
For your audience, it soundslike they don't have an example
because we haven't done it.
We don't have a large-scaleexample.
(25:08):
Hey, guess what?
What I'm saying works.
These guys tried the model andthese are the results.
Do you know of anything?
Maybe not in our country, butmaybe across the world?
What's an example of how whatwe're talking about and what we
want is out there working?
Joe Feldman (25:27):
So I really come back to care being determined on
the basis of generally acceptedstandards.
Mental health care there are abroad range of generally
(25:56):
accepted standards that havebeen developed by the, I'll say,
most experienced cliniciansthrough years and years of
training and these, thesestandards are, are revised from
time to time and they're really,I'll say, the bedrock for
determining care.
Now, one of the objections thatwe can observe is insurance
(26:19):
companies saying we are going topay for medically necessary
care where medically necessarymeans stabilization and not
treatment to recovery.
That's a very big difference,of course.
So I'll say, on the physicalhealth side, we don't see the
(26:42):
emergency room care beingcovered but the follow-up care
not being covered after thepatient has been stabilized from
their broken leg or lacerationor whatever it might be, heart
attack.
What we see is a continuum ofcare from the I'll say the
(27:04):
crisis or whatever, the incidentall the way through to recovery
, the incident all the waythrough to recovery, and it
should be the same for substanceuse and mental health care that
the generally acceptedstandards are treatment through
recovery.
That is what we should beexpecting and that's, I think.
(27:26):
To come back to the medicalnecessity letter template,
that's what the medicalnecessity letter template
supports is application ofgenerally accepted standards to
treatment through recovery.
That's the goal I really likethat.
I'll say we'll stand pat thereon that resource and that
(27:51):
clinical advocacy, that programadequacy for, say, residential
programs where a relevantclinician taking care of one of
our kids provided a medicalnecessity letter and it mattered
(28:18):
.
It was the, I'll say, a keypiece of the puzzle, if not the,
that overcame a medicalnecessity denial.
So we know they work.
Todd Weatherly (28:33):
Well, we just got to do more of it, right, and
I know we don't have a ton oftime here.
But, joe, I'd love to hear justa little bit, if you're willing
to give it to us your story ofhow you got here.
I know I gave a little bit inthe intro.
You had an adolescent child whowas in need of treatment.
You faced the denials game andthen you decided somewhere no,
(28:56):
I'm going to go after this.
Tell us a little bit about thatstory, jerry, just a bit.
Joe Feldman (29:03):
Sure.
So one of our kids needed carebeyond what we could provide
locally.
Nothing was, I'll say, helping.
And so, on the recommendationof a psychiatrist, we found a
residential program and then,shortly after the program
started, our insurance companysent us a letter this care is
(29:25):
not medically necessary andwe're going to not pay for it.
Well, I had been tipped offtwice.
So once, not long after thedeparture for residential, a
friend of mine said you know, bythe way, your insurance company
is going to get in the way here.
And I said you know, I haven'teven thought about that, but
thanks for tipping me off.
(29:45):
And then I got a call from ourkids therapist after you know
whatever, a couple of weeks inthe program, saying hey, I just
want to let you know I've got acall with Dr no later today.
That's what we call this guywho's the insurance company
representative.
He's an independentpsychiatrist and his job is to
(30:07):
come in on cases where it's timeto close it down.
And so that's the conversationwe're going to have today and
I'm I'll call you backafterwards.
And so that's exactly whathappened.
I got a call back and they saidyep, he's stopped the uh um,
approved number of days.
So, you know, fast forward.
(30:28):
Um, we filed an appeal.
We we had medical necessityletters from a couple of the
clinicians involved.
We submitted a request to ourinsurance company to have them
provide a complete file of allthe insurance correspondence and
(30:50):
documentation for this matter,which is, by the way, anyone's
right to do.
It's part of HIPAA.
As it turns out, we think ofHIPAA as the you know, don't
disclose any confidentialinformation, but there's also a
provision of HIPAA that says youcan ask for your whole file.
So I did that, and in thatwhole file was a document from
(31:11):
this psychiatrist that was afabrication of the conversation
that he'd had that day with ourkids therapist day, listening to
the therapist tell me what wasgoing to happen.
(31:32):
And then I had this independentpsychiatrist's notes to the
insurer and it was a completelydifferent conversation.
That was documented.
It was just fraudulent.
And so we filed a federallawsuit, which we won in the
Northern District of Illinois.
And so that taught me that thisis really, first of all,
litigation is a terrible way togo.
(31:54):
It takes too long.
The law is not easy to litigate.
When you're driving down thehighway and you see these
billboards that say call me andI'll get your injury case
settled, you never, ever see onethat says were you improperly
denied for medical necessity?
(32:15):
And the reason is there's nodamages, you can't sue for
damages.
So there are very, very fewlawyers that will take these
cases.
So we had a cut and dried caseor, let's say, close, and so I
found litigators who would takethe case because they can be
granted legal fees.
That's the only way they wouldwork and they care about this.
(32:37):
They also look for class actionopportunities.
Those are easier for them tomake a living, although they're
still very hard to go after.
That's what got me into thiswhole world is there are ways
that patients and families andclinicians can take steps.
That I learned about through myown experience through
(32:57):
litigation and then that I'velearned about through my
advocacy that a psychiatristfriend of mine who runs a
program here in suburban ChicagoIOP and PHP for the most part
so intensive outpatient andpartial hospitalization.
She's the one that gave me theidea for a resource that would
(33:20):
provide these ready-to-gotemplates and scripts and
worksheets and identifyingdifferent ways that patients,
families and clinicians can pushback on obstacles, and I just
thought this is.
I looked in the, I did a littlemarket research.
I found nothing like this andso I decided to give it a go and
(33:41):
we're making a lot of progress.
As I said, we're gettingsuccess stories coming in step
by step and visits to ourwebsite and collaboration with
organizations like Mental HealthAmerica and International OCD
Foundation and National Networkof Depression Centers just among
sort of consumer and diseaseand clinical facing
(34:05):
organizations, and many, manymore.
So it's really, I'll say, thebest is yet to come.
Todd Weatherly (34:13):
And our mutual friend Jordan Lewis attorney
Jordan Lewis, of course who'sout there fighting the bid fight
as well.
He's got a pretty engagingstory about all this.
I know that you and I talkedabout this.
Out there, there's Don't DenyMe the website, which is a
little bit like those.
You've got a lot more resourceson yours, of course.
We've got full-on companies outthere that are doing the
(34:33):
website, which is a little bitlike those.
You've got a lot more resourceson yours, of course.
We've got full-on companies outthere that are doing, you know,
claims management, denouncemanagement, those kinds of
things.
It always baffles me thatthere's an entire industry of
people and all they do for aliving is help people with their
denied claims.
It says something about us, Ithink.
So I'm super excited about thefact that you're out there doing
(34:55):
this work.
I look forward to it.
I'm going to be out in Chicagoin the pretty near future to
help the Missy Yellow regularprivate program out there.
You're probably familiar withthose guys and hopefully we'll
get a chance to hang out and seewhat it is.
Joe Feldman (35:10):
That sounds great.
That sounds great.
That sounds great.
Now, this is it's importantwork.
There are other resources thatare available.
What I found is many websiteswill tell you that the law is on
your side, and when you're in acrisis, that's not terribly
helpful and they'll tell youthat you know.
(35:31):
Here's how you can write abetter appeal, and what I've
learned from having gone downthat path is that appeals are
really very legalistic processesthat just fundamentally favor
insurance companies, and sothere is a time and a place for
an appeal.
There are many steps, likemedical necessity letters.
Like medical necessity letters.
We also have on our website,covermymentalhealthorg,
(35:56):
suggestions about filing formalcomplaints before an appeal so a
complaint is not an appeal andother ways to tap into allies
that you may not be aware of,like elected officials, which is
a great one, and one thing Itell families and I'd love to
get your take on this before oneand one thing I tell families
and I'd love to get your take onthis before we conclude is that
I tell families it's like askfor a case manager.
Todd Weatherly (36:18):
You want a case manager in the insurance company
.
At the very least you've gotone person paying attention to
your case and your coverage alittle closer than just the
average roofer.
And if we've got complicatedmental health conditions, go
along.
You need somebody to be playingwith it.
Usually it's a little bitbetter results, right, right.
Joe Feldman (36:38):
Now, one of the tips that clinicians tell me
they like a lot is that anyonecan authorize someone a friend
or family member to speak forthem, for their insurance
company.
You can download thatauthorization form and when
you're up to your eyeballs witha family crisis, that may be
exactly what you need to do.
Todd Weatherly (36:57):
So that's another thing that you can do
Well, I'm going to do a lot ofinvestigating on your website
and start sharing all yourresources across the board.
Joe, it's been fantastic tohave you on the show.
I think that you and I areprobably going to follow up and
do a little bit more of this, ofcourse, and I want to hear more
success stories, but this hasbeen Joe Feldman with Comfort
(37:20):
Mind Mental Health, and ToddWeatherly, your host on Inside
Mental Health.
We look forward to being withyou next time, joe, thanks for
being on the show.
Joe Feldman (37:29):
Thanks.
Thanks for the chat, thanks fora great conversation and thanks
for helping to spread the wordabout our resources.
You bet I need a little help.
(37:53):
I found a little need.
I need a little help.
I found a little need.
I need a little help.
I found a little need.
I need a little help.
I found a little need.
I need a little help.
I found a little need.
I'm used to the little love inme.
I need a little help.
I found a little need.
I'm used to the little love inme.
(38:18):
Thank you is.
Oh, I feel so lonely and lostin here.
(39:14):
I need to find my way home.
I feel so lonely and lost inhere.
I need to find my way home.
I feel so lonely and lost inhere.
I need to find my way home.
Find my way home.
Hello folks, thanks for joining us on Head
Inside Mental Health, featuringconversations about mental
health and substance usetreatment with experts,
advocates, professionals fromacross the country sharing their
thoughts and insights on theworld of behavioral health care.
Broadcasting on WPBM 1037, theVoice of National, I'm Todd
Weatherly, your host,therapeutic consultant and
behavioral health expert, andwith me today is Joe Feldman.
(00:25):
Joe is the president andfounder of Cover my Mental
Health.
Joe has been advocating foraccess to mental health care
after overcoming denials for hisadolescence residential care,
including with a successfulfederal lawsuit.
Joe established Cover my MentalHealth based on his own success
overcoming insurance obstacleswith input from leading
(00:45):
legislators, appeals experts,clinicians, insurance regulators
and former insurance industryinsiders.
Cover my Mental Health'sresources have been presented to
advocacy organizations inIllinois, georgia Tech, maryland
, connecticut and New York.
To clinical organizations,including UT Health in Houston,
westman Dunstan organizations,including UT Health in Houston,
who plays with us and does workout there with Lindner Lindner
(01:06):
as well Lindner Center of Hope,menagerie Clinic, silver Hill
Hospital, norton Healthcare.
To clinical conferences hostedby American Psychiatric
Association and the NationalCouncil for Mental Well-Being,
as well as what was the lastconference you just did, joe.
Joe Feldman (01:21):
The International OCD Foundation Conference in
Chicago.
Todd Weatherly (01:27):
That was great Covered by Mental Health has
been featured in numerousclinical and mainstream
publications, as well as ontelevision news in Cincinnati,
philadelphia and Michigan.
Joe's advocacy work hasincluded policy-driven
discussions with legislators andregulators, board role with
Kennedy Forum in Illinois,presentations to parent groups
and publication of actionableguides, such as a 2021 article
(01:50):
in the Journal of PsychiatricPractice on Medical Necessity
Letters.
Joe also serves on the board ofThresholds, a Chicago-based
firm that I support to thislevel of meaning, joe welcome to
the show.
Joe Feldman (02:05):
Thanks for having me.
That's a big introduction.
I'm going to have a tough timefilling the bill, but I'll do my
best.
Todd Weatherly (02:14):
Well, you know I'll give you a chance to live
up to it.
I have no doubt we've got alittle something in there.
You and I have gotten to talkprior to now, a little bit
through some mutual connectionswho have been running the same
circles, fighting the powersthat be for insurance coverage
and just getting to acknowledgewhat actual residential mental
(02:35):
health care should look like.
It's not seven or 12 days, youknow.
It doesn't come just fromhospitals and you are not alone.
It doesn't come just fromhospitals and you are not alone.
And this fight is far from overin terms of, you know, getting
insurance companies to recognizewhat good care is, pay for it,
understand the benefits of justpaying for good care instead of
ramming people into thisshort-term model.
(02:57):
What's the latest?
You know what's the latestsuccess that you feel like
you've achieved so far in kindof being in this fight after
you've started to come out ofthe lab.
Joe Feldman (03:10):
Well, so we have been around since the very
beginning of last year and ourwebsite's been up since May of
2024.
And we're starting,step-by-step, to hear success
stories of folks who've used ourresources to overcome insurance
obstacles.
And I can share maybe two ofthose success stories with you,
(03:30):
and this is, I'll say, reallythe goal of what we're trying to
do.
So one was from a clinicianhere in Northeastern Illinois so
I live in suburban Chicago andI had had a conversation with
this particular clinician whoworks in addiction medicine, and
we were talking about thepossibility of my coming to her
(03:52):
hospital and giving a talk aboutour resources to her and her
team.
And a couple of weeks afterthat she reached out to me and
she said I just want to let youknow that I had an occasion
where an insurance company wasstanding in the way of my
prescribing a particularmedication to one of my patients
and I was getting frustratedbecause this was sort of all too
(04:17):
familiar to me and I knewexactly from my training and
experience and from working withthis particular patient that
this med was the right choice.
It was the standard of care andI thought I'm going to go to
that website and see if I canuse the template for a medical
(04:38):
necessity letter.
And she said she used ourtemplate.
She said she used our template.
She of course adapted it to theparticular needs of her patient
.
She included the specificobjections that the insurance
(04:58):
company had put between herpatient and the necessary care.
She submitted that letter tothe insurance company and they
said we approve the delivery ofthat medication.
I was of course, thrilled, soit was.
You know.
That's I'll say.
You know, in a way, that's theway it should work.
I mean, the way it reallyshould work is the clinician
(05:19):
should have the prerogative toprovide the right medication.
But in terms of overcoming theobstacles, it was a great
example.
Todd Weatherly (05:29):
If you will, before you go into the second
example, what are the parametersin this letter, this form that
you've created, that you thinkmakes the difference?
Joe Feldman (05:40):
So a medical necessity letter is a I'll say a
tool that clinicians can use todocument who they are and the
decision making and the way Ilike to describe the template
which you can download on ourwebsite it's in Word, by the way
, so it's very easy to adapt andsort of get customized for any
(06:06):
particular use.
The way I like to describe itis it's like a conversation that
you can imagine between aclinician and the insurance
company, where the conversationgoes something like this Let me
introduce myself to you.
I was trained at the followingmedical school or the following
(06:27):
clinician program.
Let me tell you about mypractice area and my experience
there.
Let me tell you about thisparticular patient, the
relationship that we have, andwhat I've determined is the
diagnosis that we're working onin support of this patient's
recovery.
These are the generallyaccepted standards that I have
(06:50):
found applicable in thisparticular case, that guide me
to make this clinical decision.
These are some risks that I'vethought about if the patient
didn't get this care or wasasked to have care at a
different level or with adifferent med, and so, in
conclusion, this is the carethat is appropriate for this
(07:12):
patient of mine and signed bythe clinician, and so it's a
very it's very common sense sortof conversation.
It's in writing.
It includes language that wasdeveloped with input from some
of the folks that you mentionedin your kind introduction folks
(07:33):
who are litigators in this area,regulatory experts, former
insurance company executives andthe instructions that are part
of this template provide promptsand suggestions, which, of
course, a clinician can eitheruse or not use, at their
discretion, about specificlanguage that might be helpful
(07:55):
to them.
And I'll say it's ascommonsensical as that.
We're not trying to turnclinicians into lawyers.
Sensical as that.
We're not trying to turnclinicians into lawyers.
We're trying to give cliniciansan opportunity to document what
they're good at, which isapplying their training and
(08:16):
generally accepted standards toclinical care.
Todd Weatherly (08:19):
Well, and I assume, having seen, you know,
not that many necessarily ofthese the ones that I have seen
are like it's a doctor's order,for maybe it's a better
procedure or what have you, andnone of that stuff's there.
It's like this person has thisdiagnosis, we're prescribing
this treatment.
It's pretty spark as medicalrecords go.
(08:43):
What you've done is bring inall the details I've got this
training these are the acceptedparameters for this treatment,
these protocols that we see here, you know industry standard, et
cetera, et cetera, and you'velined it all up so that the
insurance company can't sitthere and basically poke holes
in something because they'vealready stated everything.
That might be the dyingquestion, which is, I mean, you
(09:07):
know, sounds really simple, butalso brilliant, right?
Joe Feldman (09:10):
You know what I think that's exactly the right
characterization.
It's brilliant in itssimplicity and I'd certainly
like to tell you that it was myidea, but it's a concept that's
been around for a long time.
What we've done is we'vebrought together really the best
available thinking about this.
We continue to evolve it.
(09:31):
I think one question that folkshave when I talk about medical
necessity letters is sort of whyare we even having this
conversation?
And one of my, I'll say,clinical experts who I go to for
questions about this is AndrewGerber, who runs Silver Hill
(09:53):
Hospital in Connecticut.
Very just, pragmatic approach,and the way he described it to
me was so straightforward.
He said this.
He said if you look in thehealth insurance policy, what it
will say is we pay formedically necessary care.
(10:16):
That's the, I'll say, the coredeterminant of whether they're
going to pay for something ornot.
And he said clinicians don'tever get trained in medical
necessity.
It's a legal term.
The clinical terms that arefamiliar to clinicians from
their training are theHippocratic Oath, do no harm to
(10:38):
the 2,500-year-old.
You know sort of I'll say,familiar in.
You know, I'll say commonculture and safe and effective,
which is a phrase we think aboutcertainly when we go to the
pharmacy and we getover-the-counter meds, we look
for products that are safe andeffective and then generally
(10:59):
accepted standards and whatAndrew said is generally
accepted standards are thebenchmark that clinicians use.
And so when you have a legalterm medical necessity on the
one side and generally acceptedstandards on the other, you've
got two different measurementtools.
It's quite possible that thosetwo measurement tools are going
(11:21):
to come up with two differentanswers.
Those two measurement tools aregoing to come up with two
different answers, and the goalof a medical necessity letter
you could think of as taking allthe air out from between those
two standards and imposingmedical necessity determinations
be based on generally acceptedstandards.
Todd Weatherly (11:40):
Let's play with this a little bit and we might
actually go back to some of yourstory.
But I was with Dr Gerberrecently and I had the chance to
ask him this question Doinsurance companies provide
coverage?
It's also for long enough.
There are treatment periodsthat insurance companies observe
(12:03):
and then there are treatmentperiods that treatment
professionals observe, and thosetwo worlds kind of far and wide
and differ quite significantly.
I asked Dr Gerber this question.
Joe Feldman (12:14):
I said if they just went ahead and paid for it.
Todd Weatherly (12:19):
you know, the argument is that no subscriber
lasts more than what 18 monthsor something like that.
So you know, even if they payfor long-term treatment you've
got a long-term treatment formental health, for a mental
health condition they pay moretreatment for 18 months Well,
they're losing subscribers thatlong and you know they're not
(12:39):
seeing the benefit of a healthyindividual, of course, just
moving on.
So that's the art.
I said yeah, but cumulativelyeverybody.
If you start paying for it, onemight get more allegiance from
subscribers.
But, more importantly, youstart creating something in the
field where people are gettingtreatment and they're getting
(13:02):
better, and even the subscriberthat needs you goes somewhere
else, but their subscriber leftthem and comes to you with the
same benefits.
If the industry saw it that way.
Now Dr Gerber said they'll neverdo that because it doesn't
really apply, it doesn't workthat way and everything else.
I mean he's a smart guy.
He had what I might view as alegitimate answer and I'm like
(13:27):
well, they might have to bite itfor a year, you know, or
possibly two.
I think the insurance companiescan afford it.
What is your thought about thisin terms of the insurance
accuracy and what we want themto do?
Do you see it being a viablething to ask insurance companies
hey, why don't we present amodel to you where you pay for
(13:47):
the whole thing?
Or do you think there's a biguphill fight for it?
What is your experience of that?
Joe Feldman (13:54):
So there's, I'll say, two different ways of
thinking or two differentconsiderations here.
One is paying for care that isrequired, that it's appropriate
to someone who is sick, and sowe know, when it comes to
diabetes care or cancer care orcardiovascular care, insurance
(14:19):
companies pay for that care allthe time, and so is there an
economic basis for paying forsomeone's heart transplant or
cholesterol medication?
I would say the answer is Idon't know.
We should take a look at that,and there are certainly studies
(14:39):
that would suggest that earliercare results in savings down the
road from higher levels of careor even inpatient requirements.
Same for mental health andsubstance use disorder.
So the idea of you've paid forcoverage and we should expect to
(14:59):
get that coverage, I thinkthat's one level in which mental
health can be treateddifferently and really, I'll say
, unfairly and arguably possiblyillegally.
The question you raised aboutthe economics is really an
interesting one.
Description is the one Isubscribe to, which is I don't
(15:24):
believe that insurance companiesor, by the way, large employers
who have self-funded planswhere they are the economic
backstop for other claims theyhire a company that looks like
an insurance company to us butit's actually just an
(15:45):
administrator of thecorporation's plan and they tell
them how many claims are paidevery month and the corporation
pays for that.
And I've heard many companies'executives say to me you know,
if we pay for care and thensomebody leaves, we're not going
to get the benefit.
So I'm a hundred percent withyou.
(16:06):
That's a say, a simplistic viewof the world, because the
employees who benefit might staywith you longer as an employee
or as a member of your insuranceplan, and if more and more
companies insurance companiesact this way, then the healthier
(16:30):
employees who had the earlyinvestment are going to find a
new home and they're going to bethe healthier, lower-risk
individuals who show up and youget the free ride.
So this is, I think, a really Idon't want to pay for somebody
(16:52):
else's gain later.
I think it's a very weakargument.
Todd Weatherly (16:56):
Right, well, and you know there's.
We have a program not far fromhere.
They have a pretty largeprofessionals program Blue
collar folks, nurses, airplanepilots and train operators,
specifically the train industryand, I believe, certain
(17:19):
companies that have plane pilots.
They have decided to just goahead and pay for it.
Right, they decided to go aheadand pay for residential
treatment, step down to PHP andthen IOP and even six months of
sober living all the way through, whether it's covered by the
(17:42):
insurance or not, because whatthey found one employee
retention for some of these isreally, really important,
especially for the trainindustry, apparently, somebody
who's experienced at doing thatwork and has years under their
belt.
They can't just lose thatposition because they've got any
(18:03):
patients.
They're paying for the wholething and the result they see is
that they come back better whenthey come back ready.
Then they come back grateful.
The outcomes are so much betterfor these individuals.
It's hard for me to believethat insurance companies don't
(18:25):
see these examples and startpicking them up.
Yeah.
Joe Feldman (18:33):
So I'll tell you two stories.
So one is one of my keyadvisors used to work in three
different insurance companiesrunning behavioral health units
different insurance companiesrunning behavioral health units
and he told me that in each ofthese organizations, as he was
getting his I'll say getting histeam together and beginning to
work together, he found that theprior authorization
(18:55):
requirements and other, I'll say, friction in the system that
was built in to slow down, ifnot deny, care was, I'll say,
standard operating procedure.
And each time he said why arewe doing this?
We're standing in the way ofour saving money and providing
better care.
And they said, well, we reallyneed to hit our percentage of
(19:20):
reviews.
And he said, ok, well, we havea different standard now.
Instead of whatever thepercentage of denials or delays
have been, I'll say the targetspoken or I'll say documented or
undocumented, he said we'regoing to go down to the next to
nothing and he said, in eachcase, they made more money, he
(19:42):
said, and people were like, ohmy gosh, that was interesting.
And he said actually, no, it'snot, it's just logical.
We're seeing it actually inaction and I think that's an
experience that would be borneout if it were applied more
(20:02):
broadly, um, the other story Iwas going to tell you is I was I
made a presentation, um aboutsix months ago, to a group of
industry uh, insurance and um,um actuary and policy folks
about the cover, my mentalhealthorg website and our
(20:22):
resources and so on.
And a couple of people who werepart of that webinar contacted
me one just after the programand one had asked a question
during the program and thesentiment that they expressed
was you know, insurancecompanies kind of get a bad rap
(20:45):
for denying care, and all thathe said.
You know, we get requests fromour customers, large
corporations, who are asking usto administer their programs,
and they tell us we want lowerfees this year, we want lower
premiums this year and thereforewe have to find a way to do
that if we want to compete forthe business.
(21:06):
And so we're doing what we'retold to do, and I thought that's
not a good steady statesolution.
Not a good steady statesolution that's being, I'll say,
(21:26):
responsive to what the customerasked for, but not what the
customer wants or needs.
What the customer wants is ahealthier workforce with overall
lower cost of care, and so itbecomes a problem when the I'll
say answer is well, we're justgoing to tighten down on care.
(21:48):
One of the other factors thatis, I think, completely relevant
here is that specialtybehavioral health programs exist
within many insurance I'll sayprograms where the
medical-surgical side is handledby one organization and the
(22:09):
behavioral health is handled byanother organization.
They can be, by the way, ownedby the same parent corporation
not necessarily, but they can beand so you have these two silos
and each one has its own incomestatement that they're looking
to manage.
Todd Weatherly (22:26):
And never the same.
Joe Feldman (22:29):
Well, let's not look broadly at what the overall
implication is for thecorporation whose plan is being
administered or the families whoare being covered.
Let's look at our narrow P&L,our profit and loss statement,
and say what do we have here?
I guess we need to spend lessthis year, and so it's just
(22:53):
unfortunate that some of thereally great analysis that's
been done by leading consultingfirms and nonprofits and
governmental organizations thatpoint to some of these potential
benefits you know, is notpersuasive yet to the folks who
(23:13):
would make it real.
Todd Weatherly (23:16):
Well, we also don't have a comparative model,
because I think the same is true.
You know, one of the thingsthat I think is a is across the
street, if you will.
Uh, though connected intimatelyto the problem that we're
talking about, which is you'vegot hospital care and you've got
outpatient care and you've gottherapists and other other.
(23:39):
You know community-basedresources for therapeutic and
mental health care and wellness.
They don't really know aboutthis specialized behavioral
health, residential treatmentand step-down and all those here
kind of side effects and what Ifind, especially in community
(23:59):
mental health resources.
What I find is they don't knowabout it.
They don't know that it exists.
They've never seen the modelsthat actually work.
They've never seen realresidential treatment.
They've never really seen whata real ACT team should do take a
PHP, delivery and schedule andpsycho-ed and all these other
(24:25):
pieces and make it interestingand make it not just a recycled
version of the last thing theydid for everybody else, and so
they just keep doing the same.
You know they only know whatthey've seen right and you know
you get a psychiatrist who triesto prescribe meds and it's like
well, you know, this person isgoing to be facing this
condition.
You hear horror stories aboutwhat trained professionals
(24:47):
doctorate level professionalsare telling people about their
care and what's possible,because they never leave their
yard, and I think they don'thave an example, though for them
an example exists.
For your audience, it soundslike they don't have an example
because we haven't done it.
We don't have a large-scaleexample.
(25:08):
Hey, guess what?
What I'm saying works.
These guys tried the model andthese are the results.
Do you know of anything?
Maybe not in our country, butmaybe across the world?
What's an example of how whatwe're talking about and what we
want is out there working?
Joe Feldman (25:27):
So I really come back to care being determined on
the basis of generally acceptedstandards.
Mental health care there are abroad range of generally
(25:56):
accepted standards that havebeen developed by the, I'll say,
most experienced cliniciansthrough years and years of
training and these, thesestandards are, are revised from
time to time and they're really,I'll say, the bedrock for
determining care.
Now, one of the objections thatwe can observe is insurance
(26:19):
companies saying we are going topay for medically necessary
care where medically necessarymeans stabilization and not
treatment to recovery.
That's a very big difference,of course.
So I'll say, on the physicalhealth side, we don't see the
(26:42):
emergency room care beingcovered but the follow-up care
not being covered after thepatient has been stabilized from
their broken leg or lacerationor whatever it might be, heart
attack.
What we see is a continuum ofcare from the I'll say the
(27:04):
crisis or whatever, the incidentall the way through to recovery
, the incident all the waythrough to recovery, and it
should be the same for substanceuse and mental health care that
the generally acceptedstandards are treatment through
recovery.
That is what we should beexpecting and that's, I think.
(27:26):
To come back to the medicalnecessity letter template,
that's what the medicalnecessity letter template
supports is application ofgenerally accepted standards to
treatment through recovery.
That's the goal I really likethat.
I'll say we'll stand pat thereon that resource and that
(27:51):
clinical advocacy, that programadequacy for, say, residential
programs where a relevantclinician taking care of one of
our kids provided a medicalnecessity letter and it mattered
(28:18):
.
It was the, I'll say, a keypiece of the puzzle, if not the,
that overcame a medicalnecessity denial.
So we know they work.
Todd Weatherly (28:33):
Well, we just got to do more of it, right, and
I know we don't have a ton oftime here.
But, joe, I'd love to hear justa little bit, if you're willing
to give it to us your story ofhow you got here.
I know I gave a little bit inthe intro.
You had an adolescent child whowas in need of treatment.
You faced the denials game andthen you decided somewhere no,
(28:56):
I'm going to go after this.
Tell us a little bit about thatstory, jerry, just a bit.
Joe Feldman (29:03):
Sure.
So one of our kids needed carebeyond what we could provide
locally.
Nothing was, I'll say, helping.
And so, on the recommendationof a psychiatrist, we found a
residential program and then,shortly after the program
started, our insurance companysent us a letter this care is
(29:25):
not medically necessary andwe're going to not pay for it.
Well, I had been tipped offtwice.
So once, not long after thedeparture for residential, a
friend of mine said you know, bythe way, your insurance company
is going to get in the way here.
And I said you know, I haven'teven thought about that, but
thanks for tipping me off.
(29:45):
And then I got a call from ourkids therapist after you know
whatever, a couple of weeks inthe program, saying hey, I just
want to let you know I've got acall with Dr no later today.
That's what we call this guywho's the insurance company
representative.
He's an independentpsychiatrist and his job is to
(30:07):
come in on cases where it's timeto close it down.
And so that's the conversationwe're going to have today and
I'm I'll call you backafterwards.
And so that's exactly whathappened.
I got a call back and they saidyep, he's stopped the uh um,
approved number of days.
So, you know, fast forward.
(30:28):
Um, we filed an appeal.
We we had medical necessityletters from a couple of the
clinicians involved.
We submitted a request to ourinsurance company to have them
provide a complete file of allthe insurance correspondence and
(30:50):
documentation for this matter,which is, by the way, anyone's
right to do.
It's part of HIPAA.
As it turns out, we think ofHIPAA as the you know, don't
disclose any confidentialinformation, but there's also a
provision of HIPAA that says youcan ask for your whole file.
So I did that, and in thatwhole file was a document from
(31:11):
this psychiatrist that was afabrication of the conversation
that he'd had that day with ourkids therapist day, listening to
the therapist tell me what wasgoing to happen.
(31:32):
And then I had this independentpsychiatrist's notes to the
insurer and it was a completelydifferent conversation.
That was documented.
It was just fraudulent.
And so we filed a federallawsuit, which we won in the
Northern District of Illinois.
And so that taught me that thisis really, first of all,
litigation is a terrible way togo.
(31:54):
It takes too long.
The law is not easy to litigate.
When you're driving down thehighway and you see these
billboards that say call me andI'll get your injury case
settled, you never, ever see onethat says were you improperly
denied for medical necessity?
(32:15):
And the reason is there's nodamages, you can't sue for
damages.
So there are very, very fewlawyers that will take these
cases.
So we had a cut and dried caseor, let's say, close, and so I
found litigators who would takethe case because they can be
granted legal fees.
That's the only way they wouldwork and they care about this.
(32:37):
They also look for class actionopportunities.
Those are easier for them tomake a living, although they're
still very hard to go after.
That's what got me into thiswhole world is there are ways
that patients and families andclinicians can take steps.
That I learned about through myown experience through
(32:57):
litigation and then that I'velearned about through my
advocacy that a psychiatristfriend of mine who runs a
program here in suburban ChicagoIOP and PHP for the most part
so intensive outpatient andpartial hospitalization.
She's the one that gave me theidea for a resource that would
(33:20):
provide these ready-to-gotemplates and scripts and
worksheets and identifyingdifferent ways that patients,
families and clinicians can pushback on obstacles, and I just
thought this is.
I looked in the, I did a littlemarket research.
I found nothing like this andso I decided to give it a go and
(33:41):
we're making a lot of progress.
As I said, we're gettingsuccess stories coming in step
by step and visits to ourwebsite and collaboration with
organizations like Mental HealthAmerica and International OCD
Foundation and National Networkof Depression Centers just among
sort of consumer and diseaseand clinical facing
(34:05):
organizations, and many, manymore.
So it's really, I'll say, thebest is yet to come.
Todd Weatherly (34:13):
And our mutual friend Jordan Lewis attorney
Jordan Lewis, of course who'sout there fighting the bid fight
as well.
He's got a pretty engagingstory about all this.
I know that you and I talkedabout this.
Out there, there's Don't DenyMe the website, which is a
little bit like those.
You've got a lot more resourceson yours, of course.
We've got full-on companies outthere that are doing the
(34:33):
website, which is a little bitlike those.
You've got a lot more resourceson yours, of course.
We've got full-on companies outthere that are doing, you know,
claims management, denouncemanagement, those kinds of
things.
It always baffles me thatthere's an entire industry of
people and all they do for aliving is help people with their
denied claims.
It says something about us, Ithink.
So I'm super excited about thefact that you're out there doing
(34:55):
this work.
I look forward to it.
I'm going to be out in Chicagoin the pretty near future to
help the Missy Yellow regularprivate program out there.
You're probably familiar withthose guys and hopefully we'll
get a chance to hang out and seewhat it is.
Joe Feldman (35:10):
That sounds great.
That sounds great.
That sounds great.
Now, this is it's importantwork.
There are other resources thatare available.
What I found is many websiteswill tell you that the law is on
your side, and when you're in acrisis, that's not terribly
helpful and they'll tell youthat you know.
(35:31):
Here's how you can write abetter appeal, and what I've
learned from having gone downthat path is that appeals are
really very legalistic processesthat just fundamentally favor
insurance companies, and sothere is a time and a place for
an appeal.
There are many steps, likemedical necessity letters.
Like medical necessity letters.
We also have on our website,covermymentalhealthorg,
(35:56):
suggestions about filing formalcomplaints before an appeal so a
complaint is not an appeal andother ways to tap into allies
that you may not be aware of,like elected officials, which is
a great one, and one thing Itell families and I'd love to
get your take on this before oneand one thing I tell families
and I'd love to get your take onthis before we conclude is that
I tell families it's like askfor a case manager.
Todd Weatherly (36:18):
You want a case manager in the insurance company
.
At the very least you've gotone person paying attention to
your case and your coverage alittle closer than just the
average roofer.
And if we've got complicatedmental health conditions, go
along.
You need somebody to be playingwith it.
Usually it's a little bitbetter results, right, right.
Joe Feldman (36:38):
Now, one of the tips that clinicians tell me
they like a lot is that anyonecan authorize someone a friend
or family member to speak forthem, for their insurance
company.
You can download thatauthorization form and when
you're up to your eyeballs witha family crisis, that may be
exactly what you need to do.
Todd Weatherly (36:57):
So that's another thing that you can do
Well, I'm going to do a lot ofinvestigating on your website
and start sharing all yourresources across the board.
Joe, it's been fantastic tohave you on the show.
I think that you and I areprobably going to follow up and
do a little bit more of this, ofcourse, and I want to hear more
success stories, but this hasbeen Joe Feldman with Comfort
(37:20):
Mind Mental Health, and ToddWeatherly, your host on Inside
Mental Health.
We look forward to being withyou next time, joe, thanks for
being on the show.
Joe Feldman (37:29):
Thanks.
Thanks for the chat, thanks fora great conversation and thanks
for helping to spread the wordabout our resources.
You bet I need a little help.
(37:53):
I found a little need.
I need a little help.
I found a little need.
I need a little help.
I found a little need.
I need a little help.
I found a little need.
I need a little help.
I found a little need.
I'm used to the little love inme.
I need a little help.
I found a little need.
I'm used to the little love inme.
(38:18):
Thank you is.
Oh, I feel so lonely and lostin here.
(39:14):
I need to find my way home.
I feel so lonely and lost inhere.
I need to find my way home.
I feel so lonely and lost inhere.
I need to find my way home.
Find my way home.
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