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What Are Residential Treatment Centers?

Residential treatment centers (“RTC”) are live-in treatment centers for people who suffer from mental health issues, substance abuse, and/or eating disorders. RTCs are often the next big step in a treatment plan when other available treatments have failed.

Treatment at an RTC can be very costly. So, it is common for a person entering an RTC to submit a claim to their health insurance carrier to cover the cost. But, unfortunately, insurance companies do not always pay these claims. Instead, insurance companies often deny these claims as not medically necessary.

If you have a residential treatment denial, call our law firm to learn how we can help. It’s important to contact us before the final denial by the insurance company.

Since most people obtain health insurance through their employer, these types of claims are often governed by a federal law called ERISA: the Employee Retirement Income Security Act.  The claim may also be governed by state law if you purchased your health insurance policy on your own.

Speak with an attorney in our office to learn more about your insurance policy and the laws that apply.

How is My ERISA Claim Reviewed?

ERISA has strict guidelines that an insurance carrier must follow. For RTC claims, insurance companies are supposed to maintain specific guidelines to be followed when making a determination on a claim. These guidelines are supposed to comply with the terms of the claimant’s insurance plan and state laws. Importantly, these guidelines should follow generally accepted standards of care. Generally Accepted Standards of Care include:

  • Standards that are widely accepted by health care professionals
  • Can come from various sources such as physician societies, practice guidelines, etc.

The person assigned to analyze the claim is called a “care advocate.” Once a claim is submitted it is analyzed on two levels:

  • Administrative and
  • Clinical.

First, the care advocate determines if the claim is appropriate on the administrative level. This determines whether there is a contractual issue. For example, is the condition covered under the policy.

Next, the care advocate makes a clinical determination. This determines whether the claim is medically necessary. If it is determined that the claim should be denied for clinical reasons, the care advocate passes the claim to a peer reviewer.

A peer reviewer can include a physician or Ph.D authorized by the insurance company to a clinical determination. The peer reviewer decides whether each claim meets the criteria set forth in the guidelines. This review typically involves a conversation with the patients doctor requesting the treatment and reviewing information put together by the Care Advocate.

The claimant and their provider are then notified in writing of the decision. If the claim is denied, the denial letter must include the reasoning for denial and cite to the various guidelines relied upon.

Is My Claim Reviewed Differently If It’s Not ERISA?

In some ways, yes, and others, no. Although insurance companies do not have to follow certain rules and procedures that apply to ERISA governed claims, they must still adhere to the terms of the insurance policy and appropriate guidelines. That means an insurance company cannot deny a residential treatment claim that is appropriate and necessary for the patient just because the insurance company believes less intensive treatment or outpatient treatment would be sufficient.

How Can We Help?

Under ERISA, a claimant has certain rights to protect them when filing claims for RTC coverage. State insurance laws also gives certain rights to policyholders. We have experience handling RTC claims and fighting against the wrongful denials by insurance carriers.

We are a law firm helping people nationwide obtain the benefits they deserve. Call us for a free evaluation of your case.