Receiving Treatment for Eating Disorders Through the Managed Care System

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July 1, 2005 at 11:56 am  •  Posted in Eating Disorders by  •  0 Comments

By Melanie Barton, MSW
 

Introduction

Anorexia Nervosa, a type of eating disorder is defined by eating miniscule amounts that do not maintain body weight, or not eating at all for an extended period of time, or using methods to induce eliminating the consumed food by either excessive exercise, laxatives, and/or self-induced vomiting. Bulimia, another type of eating disorder can involve any or all of the above behaviors plus he or she binges on food and then compulsively eliminates it.

The anorexic patient can have an irregular heartbeat and excessive body hair; major body organs can begin to shut down, and for women menstrual periods can cease. The stomach acid from vomiting can cause hemorrhaging of the esophagus and the eroding of tooth enamel for the bulimic person. This patient can also have electrolyte imbalance (the water in individual cells) from the purging. All these signs of the seriousness of the progression of an eating disorder can happen without the therapist’s awareness or training to detect such occurrences.

Treating eating disorders is complicated because it involves psychological as well as physical factors. If the trained social worker determines his or her client needs hospitalization and the insurance is managed care, the situation can become not only frustrating, but also life-threatening. In order for the client to enter an in-patient treatment facility authorization (approval) must be obtained prior to admittance. This process can take time and certain criteria must be met. Often insurance cards have a number printed on them that one can call to get answers to questions about the conditions are covered and how approval is determined.

If a client is admitted to the hospital, she will learn that there are two components to the insurance coverage. One is the mental health, or behavioral component. The other is the medical component. Different divisions of managed healthcare handle these two components. Often the two do not have communication or coordination with one another.

On the hospital unit the Utilization Review staff person arranges for approval for treatment, including physical examinations, psychological examinations, lab work, nutritional counseling, etc. Often this person gets the one component authorized, but fails to arrange for the other. Unfortunately, the patient or the patient’s family can end up owing the hospital money for services that were not preauthorized.

What Family Members Can Do To Help

There are steps families can take to help insure their loved-one is getting the best care.

  • They should ask the therapist (i.e., a social worker) if he or she is trained to detect signs of serious complications. Knowing these signs can help prevent delays in the patient getting needed medical attention.
  • They should make sure the therapist works closely with a physician who regularly treats eating disorders.
  • They should also find out what their insurance covers and how long the process takes, if hospitalization becomes necessary. If hospitalization happens, ask to speak with the Utilization Review person to make sure they have both identification numbers for the medical and behavioral components.
  • They should Insist on signing releases so one component can coordinate treatment with the other. Call and verify that both components will be treated to insure preauthorization has been obtained.
  • If the family receives a bill that they do not believe they should be responsible for, they should talk to the billing department of the hospital, and/or appeal to your insurance carrier.
  • Finally, families should not delay seeking a second opinion if they believe the therapist, doctor, or other healthcare professional is not treating the eating disorder seriously and as the life-threatening situation it is.

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The opinions expressed in this article are those of the writer, and do not necessarily reflect those of the National Association of Social Workers or its members.

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