Welcome to Why Not Me, embracing autism and mental health worldwide. Hosted by Tony Mietour. Broadcasting from the heart of Music City, USA, Nashville, Tennessee. Join us as our guest share their raw, powerful stories. Our song was far laughter. Others will move you to tears. These real-life journeys inspire, connect, and remind you that you're never alone. We're igniting a global movement to empower everyone to make a lasting difference by fostering deep awareness, unwavering acceptance, and profound understanding of autism and mental health. Tune in, be inspired, and join us in transforming the world one story at a time. Hi, I'm Tony Mietour. Welcome to Why Not Me, embracing autism and mental health worldwide. Joining us today is Joe Feldman. He's the founder and president of Cover My Mental Health, a non-profit that's arming families, clinicians, and advocates with free resources like medical necessity letter templates, appeal scripts, and insider tips to smash through those barriers. His own journey started in a fight for his own family's care and led to a groundbreaking federal lawsuit that forced and ensured to reverse wrongful denials. He joins us to tell his story, his strategy, and how it led to his advocacy to help others. So before we dive into our episode, we'll be back with an uninterrupted show right after a word from our sponsors. Thanks for joining us today. Absolutely. I appreciate your inviting me before to a conversation. It's my pleasure. Glad to have you here. If you would, tell our listeners what you do. I am focused on helping patients, families, and clinicians overcome insurance obstacles to mental health care if you do not have to take no for an answer. I think that's something we all can appreciate. So would you expand on what that actually means and then most important, how do you accomplish it? I'm here. So I started covering my mental health as a nonprofit early in 2024 with the realization that there were no resources available to patients and families at the point of an insurance crisis. By insurance crisis, I mean a denial for not medically necessary or not being able to find a suitable clinician in your insurance network, situations like that. You don't obviously know what to do. And the obstacles stand in the way of care and insurance companies really only provide one mechanism for dealing with disputes and that's an appeal and an appeal is not suitable for getting started with those obstacles getting out of the way. So over my mental health is all about providing encouragement that you don't have to ignore for an answer and then resources to back it up. Resources that you can use today to push back on insurance companies. I think this is really great. What's your first approach? And then of course, how did you get started in this? So I get started in a way that doesn't surprise anyone. Our family had a real challenge. One of our kids needed more care than we were able to locate at home and on the recommendation of psychiatrists, we thought a residential program that was suited to their needs. And very shortly after the program started, we got a letter from our insurance company that said that the care was not medically necessary and they weren't going to pay for it. I wish I could say that's not surprising. So what happened from there? We knew they were wrong and we used our savings to stay in the program and to be sure that our kid got the care they needed and to deal with the insurance company later, which I certainly recognized is a bit of a luxury. Not everyone has the ability to do that. And we did deal with the insurance company later. We want a federal lawsuit three years later and our insurance company then paid the coin that they should have paid for in the first place. I'm happy to hear that you did get reimbursed. What happened from there? That thrust me into the worry of advocacy because I thought no family should have to go through what we did and litigation, while we were successful at it, litigation is a really terrible way to access the kind of care that you should naturally get when you buy a health insurance policy. With all that happening, what were some of the things that you gained out of that as they say, knowledge is a powerful tool? It turns out there are many steps that could be taken to overcome those obstacles. Our short of litigation, or we don't guarantee that they all will work immediately even at all. We do believe that our resources will even the playing field. And we've been at it now since our website went up in May of last year and really pleased with the testimonials that we've received from both the patient and clinician use of our resources to overcome obstacles. Since you started this, do you get involved with people that are just local to your area or have you expanded to include anyone no matter where they are across the country? Our resources are relevant for all 50 states and for all private insurance. That's a big part of what we tried to do was to make our resources as universally applicable as possible and to make it easy for individuals to, when they get to our website, to see the challenge that they've got right on the website. So deny.medicine necessary or no suitable clinician in network and to be able to press that button and have it open up into resources that they can begin to use right away. No. When you say resources, can you expand on that some? Is this resources to help them against a possible insurance claim that they might have to do or is it resources that will help them find the people that they need no matter what it is to help them with themselves or a family member? So our resources are ultimately focused on patients and sometimes that means they're families. In many cases, the resources are relevant for clinicians to be involved in. First example of that is overcoming a denial or similar obstacles related to medical necessity. So a core resource that we offer is a template medical necessity letter. This template letter provides a language and the structure or a condition to write a letter to the insurance company that explains who they are, introduces themselves and practice their interactions with the patient. Their assessment of what the patient's course of treatment should be, including some risks that might be encountered if the treatment is not to that proceed. And then their sign off on the care that it's appropriate, the care that is medically necessary. So that's a document that was developed with input from a wide range of clinicians and appeals experts and litigators, former insurance company executives, state and federal regulators, and idea is that it is a way for clinicians who have never written a medical necessity letter, which by the way means pretty much all, to see in this template a common sense of explaining who they are and their ability to make a decision about clinical care and then to provide that insurance company. And we know that these letters work and they say we don't guarantee that they work every time, but they work. Now this form that they can fill out and submit, does this help them with just a single patient or does it expand to more of them being within the network of that insurance company so that way they can help more people down the road? So our research is focused on individual cases to help individual patients. In the case of directories that are incomplete or misleading, that's a real challenge for higher levels of care, where there is not a residential program, for example, in network or an intensive outpatient program in network or for certain specialty care, OCD care, for example, it is mostly available experts who are not participating in insurance networks. Now insurance companies are obliged to provide access to appropriate clinicians and we do provide resources to help a patient or a patient's family, the document that they have looked at the directory and they have done their homework to determine whether they can find an appointment somewhere soon and nearby with someone who's got the right expertise and if they can't to be able to then show their homework or worksheet that we develop to impose upon the insurance company, the obligation to find a condition is available. It's definitely a challenge because so many clinicians don't participate in insurance networks for a variety of reasons. The main one is if they don't have to and they can run a practice without doing so, that might just work for them, but it doesn't work for all the patients. How does this work when you have someone that really, really needs a lot of help? Then the insurance company, where their infinite wisdom decides we don't want to help. So the person needs to help, unfortunately, you're fighting with the insurance company to get the help. Meanwhile, that person that needs the help might be falling behind and if that happens, it could be a travesty. How do you avoid that? One of the observations that we share to deal with this or at least to try is to remind patients and clinicians, especially, that the authorization form is available for every health insurance plan so that someone can authorize a friend or a neighbor or a family number to be on their team from a, say, a legal standpoint and to be able to work with the insurance company. So I know when our family has been through challenges with either or both of our kids, we have enough friends and family and neighbors who say, is there anything we can do? You guys must be going through quite a tough stretch and we drive the carpool. Can we bring you a meal? And the answer could be, you know, for the right friend or family or member or neighbor, we authorize you to help us a little bit with the insurance. And by the way, here's a website that might give you some ideas of what to do. It's not to hand the responsibility off to someone entirely, but it's, hey, I had someone to the team. And it's not to make final decisions about anything. It's to help with some of the, just basic to asking for a copy of the insurance policy, interacting with the insurance company with regard to, say, a medical necessity wetter, submitting that to the insurance company on a timely basis. That's sort of thing. That could be a big step that people just lose track of because no one ever told them, by the way, there's an authorization form that you can use to end your team. Can you get under the mental health umbrella? You have OCD, ADHD, anxiety, bipolar, schizophrenia, so many different things. Does this cover all that? It does. It does. And in fact, the principles that we rely on in terms of an insurance company on track says we'll pay for medically necessary care. And sure as contracts says, we'll provide you with a network of clinicians. All our resources are focused on those basics. And actually, the resources apply to all healthcare, not just mental health and substance use disorder. But we know is that mental health and substance use disorder are particularly challenging for insurance coverage. We've estimated between 15 and 22 million mental health claims are denied every year by private insurance companies. That's just too many. So our goal is to provide a resource that is as universal as possible. So what are the steps in this scenario? Let's say we have someone that is in psychosis. They need help and they need it now in the worst way because if they don't get it, you don't know what kind of tragedy could happen. Is there any way of speeding the system up some to get this person the help they need and still have the insurance company be part of it right alongside them, helping them get through this? So our goal with medical necessity letters in particular, and I'll focus on that because they're that's right at the intersection of a clinician interacting with a patient. Our goal is to provide resources that empower that relationship to move as quickly as as appropriate based on that clinician's expertise in the patient's addition and prepared us to accept the care. When I talk to clinicians, I had an opportunity to present grandlions at an academic psychiatry department earlier today, talking about how medical necessity letters can be appropriate and valuable anytime a denial or slow prior authorization or change in level of care is on the horizon. But it is no from their experience when an insurance company is about to get in the way and very often a medical necessity letter can anticipate that and hopefully preempt the delay and put a munker down about their competence to make the decision. You mentioned earlier that it took you three years to get this all under control when you had your issues. Does this speed up the situation so they wouldn't have to do that? Or is there still a gap there that would create a situation where legal action unfortunately would still be something that would be on the table? I could certainly say I wish I knew then what I know now because that took a really long time and mitigation is just not a great way to go. So we're with medical necessity letters. That's early and often it really helped move things along. Do you have any examples that you can give us on how things can change because of this? For example, a psychiatrist who has used our resources presented at a meeting that we had earlier this week and she described how insurance companies would take a week or two to provide the initial prior authorization for many medications. ADHD was the particular medication which she needed permission from the insurance company to provide to her patient easily a transdremel patch because that was the right delivery mechanism for this particular patient. And she knew this insurance company was going to drag their feet. She used our template medical necessity letter to describe the patient's particular needs and she got approval in 12 hours. And as she described it, that takes the delay out of the patient, their family, the clinician, they can get back to work. So that's a, you know, that's a, to me, a remarkable story. Yeah, that's what we need to hear more stories just like that. This way they have a little hope. Another story that I've heard from another psychiatrist who's used our resources. She's found that when she has provided the medical necessity letter to an insurance company that the next time she has an interaction with a patient that has also a similar situation, it goes just a little quicker. Yeah, that's really good to hear. I really believe that the, the schematic benefit of our resources will come from that sort of empowerment of patients and clinicians, right? Because patients are confused because they deal with this only maybe once in their life or maybe only from time to time. Clinicians see this all the time and very frustrating and they're very discouraged. And to the extent that we can encourage and resource clinicians, it makes it more likely that the insurance company is, and no, they're not going to be able to walk over this clinician. This clinician knows how to stand up for themselves. Now, the one thing about insurance companies, whether we like it or not, they have vast resources. How can we effectively challenge the immense financial power and influence of insurance companies with their vast resources, lobbying efforts and legal teams? How do you work around that and how does this impact what you're doing? Well, we're not going to solve that one overnight. So one of the steps that we suggest that has been helpful, if they evening the playing field, is filing a formal complaint with the insurance company. So a formal complaint is not an appeal and it's not any regulatory complaint. It's a formal complaint to the insurance company. I wish I knew about this years ago. I only learned about this from some ex insurance company executives who helped guide the development of the resources that we put on our website. I'm very familiar with the formal complaint, along with the state insurance commission that you could go to. Would you expand on that for those that might not know? So the formal complaint works like this. You say to the insurance company, it can be orally and then follow up and writing. I want to file a formal complaint. It'd be for the quality of care failure. It could be for some other interaction where the insurance company is, let's say, behaving badly. And insurance companies have two obligations when they receive a formal complaint and they don't like either one of these two. They are obliged to report the formal complaint to their regulatory agency, other state or federal, and they're obligated to report the formal complaint to their accreditation body, which is the organization that licenses them to do business as a health insurance. How did we urac or NCQA? NCQA is the bigger one for private insurance and they don't like to do that. And so saying I want to file a formal complaint is potentially more effective than saying, for example, I'd like to speak to a supervisor where you get a no, you get a no or a delay from someone that has a slightly bigger title. Yes, they sure do know how to do that. Do you have any examples of anything that you've done or been around where this has worked? So one example of a formal complaint working that surprised me in a really positive way was this there was a clinic that specializes in OCD care in Texas and they are not in network and they have worked out in agreement among the insurance company and the patient and themselves, ever certain care at a certain rate. And that was all they needed to be able to proceed with the thinking care of this patient. So all that happened and then they sent the bill and the insurance company said we're not paying and then they said we're not paying again. And then one of the members of this clinical staff heard a presentation that I made at the International OCD Foundation conference and I described among other things, I linked a formal complaint. So they went back home and they said to their colleague, let's try again, I heard this guy talk about formal complaints, let's try it because why not? But they had another conversation, are you going to pay the bill? No. Okay. In that case, we'd like to file a formal complaint. And the insurance company reps said that checks in the mail and they got paid. That's a story to tell them the success stories link on our website. Yeah, that's great because anyone that puts the time in and does the work should get paid for doing it. That was a bit of a surprise, right? Because like I said, I didn't know about this mechanism before putting this website together and here was a scenario that I had not ever anticipated. So I don't know if that works in every case, probably not so much. And to me, the signal is, there's a hit clinical organization that knows the words and is communicating with the insurance company on their level. And so that matters. That matters. And that's a step. Yeah, that's a great step. Anything that will work to help people get where they need to be. Are there any other avenues you've used to help people get the support they need? Another step that might be helpful against the wealthy resource unlimited insurance company is getting help from an elected official. So state senator, state representative or state assembly and U.S. member of Congress, either on the set of side or on the house side. All these representatives, all these elected officials, hey, a constituent services person in their office who takes incoming calls from their constituent, they try to help. And the idea is that insurance companies are regulated and the constituent services folks want to help. So if you've taken the first steps, for example, by laying a medical necessity letter and they say, sorry, we're still lacking a pay. And you file a formal complaint and they say, not good enough. Then to be able to call the constituent services and say, I need your help because insurance company is standing in the way of care. And I've done what's reasonable for me to do and I'd like to get your help. So I've validated this in a couple different ways. I had a conversation with my state representative and she told me that she takes calls in her office from individuals who were looking for help with insurance among other issues. She said, we love those calls because we get to help people by calling the insurance company and saying this was such and so from representative XYZ's office. And we want to know what you're doing to our constituent. Yes, that is just really good because sometimes that's what it takes is to get an extra person in there that's got a little more power to help them out. The other, I'll say, validation was a presentation that I made to a group at NAMI, Texas. It was for their annual conference and I described this step and a woman stood up in the back and said, I just want to say that this is 100% true and it's my job. I work in the Texas legislature and I take these calls when someone brings me the story and tells me what they've already done themselves because I don't start from square one, but when they tell me what they've done, I can call the insurance company. And she said, within a day or two, almost all the time, I get the insurance company to put it out. I've got a video of her telling that story on the website. After she said that, I said, oh my gosh, that's awesome. And I record you out in the hall afterwards and she said, absolutely. She's just great, right? She's soft spoken, determined. You don't want to be on the other side of that, right? Absolutely. Don't want to be on the wrong side of her. Now it's definitely great to get a chance to get out there and meet people and speak to them. What's some of the interesting things that might have been said to you at one of your speaking engagements? I presented to a group of clinicians at the Meninger Clinic in Houston, which is one of the top mental health programs in the country. In the Q&A, there were 80 clinicians in the room at 20 more on Zoom. We had a great banter and it was really just super productive. And one of the clinicians near the end said, you know, this is all great, but I find you just sometimes have to get angry. I said, well, you should do whatever works for you. I can tell you this though, I don't know how to teach angry. I know how to teach common sense. I'm not really teaching you anything. I'm alerting you to what you already know. I've been trying to think about how to say that in a way that sort of, we've been a vowsy, right? You have the ability to do it all along. Now we're going to get to it. Yeah, I think that's just great. And you just said it. So how do people contact you? Our website is covermymentalhealth.org. We are a nonprofit. All of our resources are no cost. We have email contact at call them on mentalhealth.com. You're welcome to use to send us your ideas. Certainly welcome contributions, but there's no cost to use the resources. And people can also help by sharing our resources with folks who may benefit from them. Half of adults in America will encounter a mental health issue in their life. So we, we being folks who can use these resources are everywhere. And just spreading a word would really be helpful, right? Be grateful. Now, in closing, what would you like to tell the listeners that you think is very important? Not only about what you're doing, but how what you're doing can help so many people across the country. So I want them to believe that they do not have to take no for an answer with health insurance companies and that their common sense expectations of their insurance company are completely reasonable. And by health insurance, they expect that there's going to be a networked electorate that they can use to identify clinicians. That's so basic. It's a reasonable expectation. They expect that those clinicians are going to be able to make decisions about their care that are going to be covered by insurance. And that that's going to persist through their treatment plan as they have a higher level of care, new meds, a different location, some duration, that should all be covered. And then if the claims paid subject to deductibles and copays, we understand that's part of the deal. And if there's a dispute, the dispute should be resolved with the patient in mind. These are all common sense expectations. And you are your own best advocate. So a little bit of encouragement. Maybe help from a friend or neighbor, but you are your own best advocate. Yeah, absolutely. Well, this has been great. Great information, great conversation. I really appreciate you taking the time to join us today. Tony, I'm grateful for the conversation with you and to help spread the word. I come from a belief that if you save one person, you save the world. So if one listener benefits from this, we've had a great day. Absolutely. That's exactly the same way I feel too. I've really enjoyed it. Thanks again. Thanks for taking time out of your busy schedule to listen to our show today. We hope you enjoyed it as much as we enjoyed bringing it to you. If you know someone who has a story to share, tell them to contact us at whynotme.world. One last thing, spread the word about why not me. Our conversations, our inspiring guests, the show you are not alone in this world. If you liked the show, please take a moment to rate, review and subscribe. It really does help the show to grow. Thank you for listening.
