DES MOINES, Iowa -- Wellmark Blue Cross and Blue Shield insures 80% of Iowans, but when it comes to some conditions, some providers say the company isn't paying what's it's promised and paid for through premiums.
For the last year and half, Mindy Pfab says her experience with Wellmark has been an ongoing battle. She says Wellmark denied her insurance coverage while she was seeking treatment at an eating disorder treatment center. She received a bill showing she owed just under $50,000.
After battling anorexia and excessive exercising for more than half her life, last spring Pfab sought treatment at Iowa's only eating disorder treatment center. However, her doctors determined she needed more extensive, inpatient care.
"There aren't enough programs here in Iowa, so you have to go out of state," she says.
Before checking into The Emily Program in Minnesota, the Cedar Rapids resident says she did the leg work ahead of time, verifying her benefits with Wellmark to make sure her insurance plan would cover her stay.
The Emily Program says Pfab should have been covered. As standard protocol, it, too, verified her benefits with Wellmark before Pfab began treatment. The program released documents to Channel 13 showing its communication between the insurance company regarding Pfab's benefits. It shows she met her deductible and out-of-pocket expenses and that Wellmark would cover Pfab's treatment in full. Due to the level of treatment Pfab was seeking, Wellmark did not require pre-authorization.
Jillian Lampert, the director of The Emily Program, calls Wellmark's denial unfair.
"If someone needs medical services, they would get it in other circumstances," she says.
According to its website, The Emily Program is nationally recognized. Approximately 15 Iowans are referred there every year. Lampert says the program has experienced a history of Wellmark denying coverage, and began noticing the pattern last year. As a result, the center made the decision to no longer accept patients from Iowa.
"When we had a really strong sense that their insurance company wouldn't cover it even through we were told that it was covered, we came to the conclusion that we couldn't put families in that situation," Lampert says. She tells Channel 13 the program began "cautiously" re-accepting those patients about four months ago.
Lampert adds there's a stigma regarding eating disorders and an underlying tone among some insures that treatment isn't medically necessary.
"I don't think people understand. This is a brain-based biological mental illness people need treatment from."
Michelle Roling, a licensed mental health therapist and co-founder of the Eating Disorder Coalition of Iowa, says Wellmark's denials are creating a crippling ripple effect.
"Many of us are treating individuals in an outpatient setting when we really know what they need is a higher level of care," she says.
Roling says that's because treatment options are limited and many times insurers won't pay for it. After spending several weeks in treatment, Pfab says if she ever needed treatment in the future, she wouldn't seek it.
Pfab appealed her claim three times. She's maxed out the appeals process Wellmark encourages. Wellmark reimbursed her about $20,000 but still insists she owes the remaining $26,000. Pfab claims Wellmark cited the reason for the denial as a lack of sufficient documents. Wellmark would not confirm those details.
"If you say I'm not meeting criteria, I want to know what the criteria is so you can point and say, 'this doesn't meet it,'" Pfab says.
"We want our members to get the right care"
Wellmark officials wouldn't not speak specifically about Pfab's case, citing patient confidentiality despite the woman giving Wellmark authorization to release her file to Channel 13. In a statement, Teresa Roof, a spokesperson for Wellmark, encourages all consumers to have an advocate when searching for a treatment program and to ask questions before beginning treatment.
"No widespread abuse of denials"
According to the Iowa Insurance Division, in the last year, five appeals have been made for members whose eating disorder treatment was denied. Division spokesperson Chance McElhaney says the denials are rare and not the result of widespread abuse in the insurance company.
Officials urge consumers whose claims have been denied to always appeal. The standard appeal process begins at an internal level through the insurance company and then to an external third-party appeal, made up of a team of doctors who determine if a claim should or should not be covered. McElhaney adds a consumer can also take the case to district court or sue the insurance company.
"An insurance product is basically a contract between the insurer and individual and has certain benefits. We can make sure the benefits are covered, but an insurer isn’t obligated to go outside of what is in their benefit package and basically what the insurer is paying their premium for."
Click here for the Iowa Insurance Division complaint form.