Head Inside Mental Health
Todd Weatherly, Therapeutic Consultant and behavioral health expert hosts #Head-Inside Mental Health featuring conversations about mental health and substance use treatment with experts from across the country sharing their thoughts and insights on the world of behavioral health care.
Head Inside Mental Health
Cover my Mental Health with Joe Feldman
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.
Hello folks, thanks for joining us on Head Inside Mental Health, featuring conversations about mental health and substance use treatment with experts, advocates, professionals from across the country sharing their thoughts and insights on the world of behavioral health care. Broadcasting on WPBM 1037, the Voice of National, I'm Todd Weatherly, your host, therapeutic consultant and behavioral health expert, and with me today is Joe Feldman. Joe is the president and founder of Cover my Mental Health. Joe has been advocating for access to mental health care after overcoming denials for his adolescence residential care, including with a successful federal lawsuit. Joe established Cover my Mental Health based on his own success overcoming insurance obstacles with input from leading legislators, appeals experts, clinicians, insurance regulators and former insurance industry insiders.
Todd Weatherly:Cover my Mental Health's resources have been presented to advocacy organizations in Illinois, 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 work out there with Lindner Lindner as well Lindner Center of Hope, menagerie Clinic, silver Hill Hospital, norton Healthcare. To clinical conferences hosted by American Psychiatric Association and the National Council for Mental Well-Being, as well as what was the last conference you just did, joe.
Joe Feldman:The International OCD Foundation Conference in Chicago.
Todd Weatherly:That was great Covered by Mental Health has been featured in numerous clinical and mainstream publications, as well as on television news in Cincinnati, philadelphia and Michigan. Joe's advocacy work has included policy-driven discussions with legislators and regulators, board role with Kennedy Forum in Illinois, presentations to parent groups and publication of actionable guides, such as a 2021 article in the Journal of Psychiatric Practice on Medical Necessity Letters. Joe also serves on the board of Thresholds, a Chicago-based firm that I support to this level of meaning, joe welcome to the show.
Joe Feldman:Thanks for having me. That's a big introduction. I'm going to have a tough time filling the bill, but I'll do my best.
Todd Weatherly:Well, you know I'll give you a chance to live up to it. I have no doubt we've got a little something in there. You and I have gotten to talk prior to now, a little bit through some mutual connections who have been running the same circles, fighting the powers that be for insurance coverage and just getting to acknowledge what actual residential mental health care should look like. It's not seven or 12 days, you know. It doesn't come just from hospitals and you are not alone. It doesn't come just from hospitals and you are not alone. And this fight is far from over in terms of, you know, getting insurance companies to recognize what good care is, pay for it, understand the benefits of just paying for good care instead of ramming people into this short-term model. What's the latest? You know what's the latest success that you feel like you've achieved so far in kind of being in this fight after you've started to come out of the lab.
Joe Feldman:Well, so we have been around since the very beginning of last year and our website's been up since May of 2024. And we're starting, step-by-step, to hear success stories of folks who've used our resources to overcome insurance obstacles. And I can share maybe two of those success stories with you, and this is, I'll say, really the goal of what we're trying to do. So one was from a clinician here in Northeastern Illinois so I live in suburban Chicago and I had had a conversation with this particular clinician who works in addiction medicine, and we were talking about the possibility of my coming to her hospital and giving a talk about our resources to her and her team. And a couple of weeks after that she reached out to me and she said I just want to let you know that I had an occasion where an insurance company was standing in the way of my prescribing a particular medication to one of my patients and I was getting frustrated because this was sort of all too familiar to me and I knew exactly from my training and experience and from working with this particular patient that this med was the right choice. It was the standard of care and I thought I'm going to go to that website and see if I can use the template for a medical necessity letter.
Joe Feldman:And she said she used our template. She said she used our template. She of course adapted it to the particular needs of her patient. She included the specific objections that the insurance company had put between her patient and the necessary care. She submitted that letter to the insurance company and they said we approve the delivery of that medication. I was of course, thrilled, so it was. You know. That's I'll say. You know, in a way, that's the way it should work. I mean, the way it really should work is the clinician should have the prerogative to provide the right medication. But in terms of overcoming the obstacles, it was a great example.
Todd Weatherly:If you will, before you go into the second example, what are the parameters in this letter, this form that you've created, that you think makes the difference?
Joe Feldman:So a medical necessity letter is a I'll say a tool that clinicians can use to document who they are and the decision making and the way I like to describe the template which you can download on our website it's in Word, by the way, so it's very easy to adapt and sort of get customized for any particular use. The way I like to describe it is it's like a conversation that you can imagine between a clinician and the insurance company, where the conversation goes something like this Let me introduce myself to you. I was trained at the following medical school or the following clinician program. Let me tell you about my practice area and my experience there. Let me tell you about this particular patient, the relationship that we have, and what I've determined is the diagnosis that we're working on in support of this patient's recovery. These are the generally accepted standards that I have found applicable in this particular case, that guide me to make this clinical decision. These are some risks that I've thought about if the patient didn't get this care or was asked to have care at a different level or with a different med, and so, in conclusion, this is the care that is appropriate for this patient of mine and signed by the clinician, and so it's a very it's very common sense sort of conversation.
Joe Feldman:It's in writing. It includes language that was developed with input from some of the folks that you mentioned in your kind introduction folks who are litigators in this area, regulatory experts, former insurance company executives and the instructions that are part of this template provide prompts and suggestions, which, of course, a clinician can either use or not use, at their discretion, about specific language that might be helpful to them. And I'll say it's as commonsensical as that. We're not trying to turn clinicians into lawyers. Sensical as that. We're not trying to turn clinicians into lawyers. We're trying to give clinicians an opportunity to document what they're good at, which is applying their training and generally accepted standards to clinical care.
Todd Weatherly:Well, and I assume, having seen, you know, not that many necessarily of these 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, and none of that stuff's there. It's like this person has this diagnosis, we're prescribing this treatment. It's pretty spark as medical records go. What you've done is bring in all the details I've got this training these are the accepted parameters for this treatment, these protocols that we see here, you know industry standard, et cetera, et cetera, and you've lined it all up so that the insurance company can't sit there and basically poke holes in something because they've already stated everything. That might be the dying question, which is, I mean, you know, sounds really simple, but also brilliant, right?
Joe Feldman:You know what I think that's exactly the right characterization. It's brilliant in its simplicity and I'd certainly like to tell you that it was my idea, but it's a concept that's been around for a long time. What we've done is we've brought together really the best available thinking about this. We continue to evolve it. I think one question that folks have when I talk about medical necessity letters is sort of why are we even having this conversation? And one of my, I'll say, clinical experts who I go to for questions about this is Andrew Gerber, who runs Silver Hill Hospital in Connecticut.
Joe Feldman:Very just, pragmatic approach, and the way he described it to me was so straightforward. He said this. He said if you look in the health insurance policy, what it will say is we pay for medically necessary care. That's the, I'll say, the core determinant of whether they're going to pay for something or not. And he said clinicians don't ever get trained in medical necessity. It's a legal term.
Joe Feldman:The clinical terms that are familiar to clinicians from their training are the Hippocratic Oath, do no harm to the 2,500-year-old. You know sort of I'll say, familiar in. You know, I'll say common culture and safe and effective, which is a phrase we think about certainly when we go to the pharmacy and we get over-the-counter meds, we look for products that are safe and effective and then generally accepted standards and what Andrew said is generally accepted standards are the benchmark that clinicians use. And so when you have a legal term medical necessity on the one side and generally accepted standards on the other, you've got two different measurement tools. It's quite possible that those two measurement tools are going to come up with two different answers. Those two measurement tools are going to come up with two different answers, and the goal of a medical necessity letter you could think of as taking all the air out from between those two standards and imposing medical necessity determinations be based on generally accepted standards.
Todd Weatherly:Let's play with this a little bit and we might actually go back to some of your story. But I was with Dr Gerber recently and I had the chance to ask him this question Do insurance companies provide coverage? It's also for long enough. There are treatment periods that insurance companies observe and then there are treatment periods that treatment professionals observe, and those two worlds kind of far and wide and differ quite significantly. I asked Dr Gerber this question.
Joe Feldman:I said if they just went ahead and paid for it.
Todd Weatherly:you know, the argument is that no subscriber lasts more than what 18 months or something like that. So you know, even if they pay for long-term treatment you've got a long-term treatment for mental health, for a mental health condition they pay more treatment for 18 months Well, they're losing subscribers that long and you know they're not seeing the benefit of a healthy individual, of course, just moving on. So that's the art. I said yeah, but cumulatively everybody. If you start paying for it, one might get more allegiance from subscribers. But, more importantly, you start creating something in the field where people are getting treatment and they're getting better, and even the subscriber that needs you goes somewhere else, but their subscriber left them and comes to you with the same benefits. If the industry saw it that way.
Todd Weatherly:Now Dr Gerber said they'll never do that because it doesn't really apply, it doesn't work that way and everything else. I mean he's a smart guy. He had what I might view as a legitimate answer and I'm like well, they might have to bite it for a year, you know, or possibly two. I think the insurance companies can afford it. What is your thought about this in terms of the insurance accuracy and what we want them to do? Do you see it being a viable thing to ask insurance companies hey, why don't we present a model to you where you pay for the whole thing? Or do you think there's a big uphill fight for it? What is your experience of that?
Joe Feldman:So there's, I'll say, two different ways of thinking or two different considerations here. One is paying for care that is required, that it's appropriate to someone who is sick, and so we know, when it comes to diabetes care or cancer care or cardiovascular care, insurance companies pay for that care all the time, and so is there an economic basis for paying for someone's heart transplant or cholesterol medication? I would say the answer is I don't know. We should take a look at that, and there are certainly studies that would suggest that earlier care results in savings down the road from higher levels of care or even inpatient requirements. Same for mental health and substance use disorder. So the idea of you've paid for coverage and we should expect to get that coverage, I think that's one level in which mental health can be treated differently and really, I'll say, unfairly and arguably possibly illegally.
Joe Feldman:The question you raised about the economics is really an interesting one.
Joe Feldman:Description is the one I subscribe to, which is I don't believe that insurance companies or, by the way, large employers who have self-funded plans where they are the economic backstop for other claims they hire a company that looks like an insurance company to us but it's actually just an administrator of the corporation's plan and they tell them how many claims are paid every month and the corporation pays for that.
Joe Feldman:And I've heard many companies' executives say to me you know, if we pay for care and then somebody leaves, we're not going to get the benefit. So I'm a hundred percent with you. That's a say, a simplistic view of the world, because the employees who benefit might stay with you longer as an employee or as a member of your insurance plan, and if more and more companies insurance companies act this way, then the healthier employees who had the early investment are going to find a new home and they're going to be the healthier, lower-risk individuals who show up and you get the free ride. So this is, I think, a really I don't want to pay for somebody else's gain later. I think it's a very weak argument.
Todd Weatherly:Right, well, and you know there's. We have a program not far from here. They have a pretty large professionals program Blue collar folks, nurses, airplane pilots and train operators, specifically the train industry and, I believe, certain companies that have plane pilots. They have decided to just go ahead and pay for it. Right, they decided to go ahead and pay for residential treatment, step down to PHP and then IOP and even six months of sober living all the way through, whether it's covered by the insurance or not, because what they found one employee retention for some of these is really, really important, especially for the train industry, apparently, somebody who's experienced at doing that work and has years under their belt. They can't just lose that position because they've got any patients. They're paying for the whole thing and the result they see is that they come back better when they come back ready. Then they come back grateful. The outcomes are so much better for these individuals. It's hard for me to believe that insurance companies don't see these examples and start picking them up. Yeah.
Joe Feldman:So I'll tell you two stories. So one is one of my key advisors used to work in three different insurance companies running behavioral health units different insurance companies running behavioral health units and he told me that in each of these organizations, as he was getting his I'll say getting his team together and beginning to work together, he found that the prior authorization requirements and other, I'll say, friction in the system that was built in to slow down, if not deny, care was, I'll say, standard operating procedure. And each time he said why are we doing this? We're standing in the way of our saving money and providing better care. And they said, well, we really need to hit our percentage of reviews. And he said, ok, well, we have a different standard now. Instead of whatever the percentage of denials or delays have been, I'll say the target spoken or I'll say documented or undocumented, he said we're going to go down to the next to nothing and he said, in each case, they made more money, he said, and people were like, oh my gosh, that was interesting. And he said actually, no, it's not, it's just logical. We're seeing it actually in action and I think that's an experience that would be borne out if it were applied more broadly, um, the other story I was going to tell you is I was I made a presentation, um about six months ago, to a group of industry uh, insurance and um, um actuary and policy folks about the cover, my mental healthorg website and our resources and so on.
Joe Feldman:And a couple of people who were part of that webinar contacted me one just after the program and one had asked a question during the program and the sentiment that they expressed was you know, insurance companies kind of get a bad rap for denying care, and all that he said. You know, we get requests from our customers, large corporations, who are asking us to administer their programs, and they tell us we want lower fees this year, we want lower premiums this year and therefore we have to find a way to do that if we want to compete for the business. And so we're doing what we're told to do, and I thought that's not a good steady state solution. Not a good steady state solution that's being, I'll say, responsive to what the customer asked for, but not what the customer wants or needs.
Joe Feldman:What the customer wants is a healthier workforce with overall lower cost of care, and so it becomes a problem when the I'll say answer is well, we're just going to tighten down on care. One of the other factors that is, I think, completely relevant here is that specialty behavioral health programs exist within many insurance I'll say programs where the medical-surgical side is handled by one organization and the behavioral health is handled by another organization. They can be, by the way, owned by the same parent corporation not necessarily, but they can be and so you have these two silos and each one has its own income statement that they're looking to manage.
Todd Weatherly:And never the same.
Joe Feldman:Well, let's not look broadly at what the overall implication is for the corporation whose plan is being administered or the families who are 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 less this year, and so it's just unfortunate that some of the really great analysis that's been done by leading consulting firms and nonprofits and governmental organizations that point to some of these potential benefits you know, is not persuasive yet to the folks who would make it real.
Todd Weatherly:Well, we also don't have a comparative model, because I think the same is true. You know, one of the things that I think is a is across the street, if you will. Uh, though connected intimately to the problem that we're talking about, which is you've got hospital care and you've got outpatient care and you've got therapists and other other. You know community-based resources for therapeutic and mental health care and wellness. They don't really know about this specialized behavioral health, residential treatment and step-down and all those here kind of side effects and what I find, especially in community mental health resources. What I find is they don't know about it. They don't know that it exists. They've never seen the models that actually work. They've never seen real residential treatment. They've never really seen what a real ACT team should do take a PHP, delivery and schedule and psycho-ed and all these other pieces and make it interesting and make it not just a recycled version of the last thing they did for everybody else, and so they just keep doing the same. You know they only know what they've seen right and you know you get a psychiatrist who tries to prescribe meds and it's like well, you know, this person is going to be facing this condition.
Todd Weatherly:You hear horror stories about what trained professionals doctorate level professionals are telling people about their care and what's possible, because they never leave their yard, and I think they don't have an example, though for them an example exists. For your audience, it sounds like they don't have an example because we haven't done it. We don't have a large-scale example. Hey, guess what? What I'm saying works. These guys tried the model and these are the results. Do you know of anything? Maybe not in our country, but maybe across the world? What's an example of how what we're talking about and what we want is out there working?
Joe Feldman:So I really come back to care being determined on the basis of generally accepted standards. Mental health care there are a broad range of generally accepted standards that have been developed by the, I'll say, most experienced clinicians through years and years of training and these, these standards are, are revised from time to time and they're really, I'll say, the bedrock for determining care. Now, one of the objections that we can observe is insurance companies saying we are going to pay for medically necessary care where medically necessary means stabilization and not treatment to recovery. That's a very big difference, of course. So I'll say, on the physical health side, we don't see the emergency room care being covered but the follow-up care not being covered after the patient has been stabilized from their broken leg or laceration or whatever it might be, heart attack.
Joe Feldman:What we see is a continuum of care from the I'll say the crisis or whatever, the incident all the way through to recovery, the incident all the way through to recovery, and it should be the same for substance use and mental health care that the generally accepted standards are treatment through recovery. That is what we should be expecting and that's, I think. To come back to the medical necessity letter template, that's what the medical necessity letter template supports is application of generally accepted standards to treatment through recovery. That's the goal I really like that.
Joe Feldman:I'll say we'll stand pat there on that resource and that clinical advocacy, that program adequacy for, say, residential programs where a relevant clinician taking care of one of our kids provided a medical necessity letter and it mattered. It was the, I'll say, a key piece of the puzzle, if not the, that overcame a medical necessity denial. So we know they work.
Todd Weatherly:Well, we just got to do more of it, right, and I know we don't have a ton of time here. But, joe, I'd love to hear just a little bit, if you're willing to give it to us your story of how you got here. I know I gave a little bit in the intro. You had an adolescent child who was in need of treatment. You faced the denials game and then you decided somewhere no, I'm going to go after this. Tell us a little bit about that story, jerry, just a bit.
Joe Feldman:Sure. So one of our kids needed care beyond what we could provide locally. Nothing was, I'll say, helping. And so, on the recommendation of a psychiatrist, we found a residential program and then, shortly after the program started, our insurance company sent us a letter this care is not medically necessary and we're going to not pay for it. Well, I had been tipped off twice. So once, not long after the departure for residential, a friend of mine said you know, by the way, your insurance company is going to get in the way here. And I said you know, I haven't even thought about that, but thanks for tipping me off. And then I got a call from our kids therapist after you know whatever, a couple of weeks in the program, saying hey, I just want to let you know I've got a call with Dr no later today. That's what we call this guy who's the insurance company representative. He's an independent psychiatrist and his job is to come in on cases where it's time to close it down. And so that's the conversation we're going to have today and I'm I'll call you back afterwards. And so that's exactly what happened. I got a call back and they said yep, he's stopped the uh um, approved number of days. So, you know, fast forward.
Joe Feldman:Um, we filed an appeal. We we had medical necessity letters from a couple of the clinicians involved. We submitted a request to our insurance company to have them provide a complete file of all the insurance correspondence and 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 of HIPAA as the you know, don't disclose any confidential information, but there's also a provision of HIPAA that says you can ask for your whole file. So I did that, and in that whole file was a document from this psychiatrist that was a fabrication of the conversation that he'd had that day with our kids therapist day, listening to the therapist tell me what was going to happen. And then I had this independent psychiatrist's notes to the insurer and it was a completely different conversation. That was documented. It was just fraudulent. And so we filed a federal lawsuit, which we won in the Northern District of Illinois. And so that taught me that this is really, first of all, litigation is a terrible way to go.
Joe Feldman:It takes too long. The law is not easy to litigate. When you're driving down the highway and you see these billboards that say call me and I'll get your injury case settled, you never, ever see one that says were you improperly denied for medical necessity? And the reason is there's no damages, you can't sue for damages. So there are very, very few lawyers that will take these cases. So we had a cut and dried case or, let's say, close, and so I found litigators who would take the case because they can be granted legal fees. That's the only way they would work and they care about this. They also look for class action opportunities. Those are easier for them to make a living, although they're still very hard to go after.
Joe Feldman:That's what got me into this whole world is there are ways that patients and families and clinicians can take steps.
Joe Feldman:That I learned about through my own experience through litigation and then that I've learned about through my advocacy that a psychiatrist friend of mine who runs a program here in suburban Chicago IOP and PHP for the most part so intensive outpatient and partial hospitalization. She's the one that gave me the idea for a resource that would provide these ready-to-go templates and scripts and worksheets and identifying different ways that patients, families and clinicians can push back on obstacles, and I just thought this is. I looked in the, I did a little market research. I found nothing like this and so I decided to give it a go and we're making a lot of progress. As I said, we're getting success stories coming in step by step and visits to our website and collaboration with organizations like Mental Health America and International OCD Foundation and National Network of Depression Centers just among sort of consumer and disease and clinical facing organizations, and many, many more. So it's really, I'll say, the best is yet to come.
Todd Weatherly:And our mutual friend Jordan Lewis attorney Jordan Lewis, of course who's out there fighting the bid fight as well. He's got a pretty engaging story about all this. I know that you and I talked about this. Out there, there's Don't Deny Me the website, which is a little bit like those. You've got a lot more resources on yours, of course. We've got full-on companies out there that are doing the website, which is a little bit like those. You've got a lot more resources on yours, of course. We've got full-on companies out there that are doing, you know, claims management, denounce management, those kinds of things.
Todd Weatherly:It always baffles me that there's an entire industry of people and all they do for a living is help people with their denied claims. It says something about us, I think. So I'm super excited about the fact that you're out there doing this work. I look forward to it. I'm going to be out in Chicago in the pretty near future to help the Missy Yellow regular private program out there. You're probably familiar with those guys and hopefully we'll get a chance to hang out and see what it is.
Joe Feldman:That sounds great. That sounds great. That sounds great. Now, this is it's important work. There are other resources that are available.
Joe Feldman:What I found is many websites will tell you that the law is on your side, and when you're in a crisis, that's not terribly helpful and they'll tell you that you know. Here's how you can write a better appeal, and what I've learned from having gone down that path is that appeals are really very legalistic processes that just fundamentally favor insurance companies, and so there is a time and a place for an appeal. There are many steps, like medical necessity letters. Like medical necessity letters. We also have on our website, covermymentalhealthorg, suggestions about filing formal complaints before an appeal so a complaint is not an appeal and other ways to tap into allies that you may not be aware of, like elected officials, which is a great one, and one thing I tell families and I'd love to get your take on this before one and one thing I tell families and I'd love to get your take on this before we conclude is that I tell families it's like ask for a case manager.
Todd Weatherly:You want a case manager in the insurance company. At the very least you've got one person paying attention to your case and your coverage a little closer than just the average roofer. And if we've got complicated mental health conditions, go along. You need somebody to be playing with it. Usually it's a little bit better results, right, right.
Joe Feldman:Now, one of the tips that clinicians tell me they like a lot is that anyone can authorize someone a friend or family member to speak for them, for their insurance company. You can download that authorization form and when you're up to your eyeballs with a family crisis, that may be exactly what you need to do.
Todd Weatherly:So that's another thing that you can do Well, I'm going to do a lot of investigating on your website and start sharing all your resources across the board. Joe, it's been fantastic to have you on the show. I think that you and I are probably going to follow up and do a little bit more of this, of course, and I want to hear more success stories, but this has been Joe Feldman with Comfort Mind Mental Health, and Todd Weatherly, your host on Inside Mental Health. We look forward to being with you next time, joe, thanks for being on the show.
Joe Feldman:Thanks. Thanks for the chat, thanks for a great conversation and thanks for helping to spread the word about our resources. You bet 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 need a little help. I found a little need. I'm used to the little love in me. I need a little help. I found a little need. I'm used to the little love in me. Thank you is. Oh, I feel so lonely and lost in here. I need to find my way home. I feel so lonely and lost in here. I need to find my way home. I feel so lonely and lost in here. I need to find my way home. Find my way home.