health Insurance Article

Mental Health and Insurance: New Diagnoses and Changes to Existing Disorders

Mental illnesses affect the behaviors and habits of approximately one in five Americans, but only about 60% of sufferers receive treatment each year for their illness. As information continues to develop, mental health professionals must stay current and educated on how to diagnose all the disorders.

With the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) set to be released in May, additions and revisions to some of the mental disorders stand to greatly impact patients and insurance providers.

(Read part one of this series on coverage for severe and life-threatening conditions, and part two on commonly misunderstood illnesses.)

New Disorders

DSM-5 will include additions of some new mental disorders. Some of the new disorders recognized will be:

  • Hoarding Disorder: People were made more aware of this mental illness by the popular television show Hoarders, which brought mental illness right into America’s living room. People with hoarding disorder excessively save items others may view as worthless. They experience extreme difficulty parting with their possessions, which can potentially lead to health and safety concerns. It’s estimated that 2% to 5% of the population has hoarding disorder.
  • Skin Picking Disorder: People with skin picking disorder, known as trichotillomania, pick their skin repeatedly, often bad enough to cause tissue damage. People pick their skin for different reasons — boredom, habit, to cope with negative emotions, or in response to feelings of tension and stress. Skin picking disorder is sometimes referred to as an ‘obsessive compulsive spectrum disorder’ because symptoms are similar to those of OCD. An estimated one in 20 are affected from skin picking disorder.
  • Disruptive Mood Dysregulation Disorder (DMDD): This has been said to be a better diagnosis for individuals, especially children, who are often misdiagnosed as having bipolar disorder. Those who suffer from bipolar disorder are often prescribed mood stabilizer medications and sometimes antipsychotics and antidepressants that have strong side effects. The DMDD diagnosis is said to be for children ages six to 18 who have extreme temper outbursts three or more times a week. While some feel DMDD will be a more accurate diagnosis and cut down on overmedicating, there are some critics who say the new diagnosis of DMDD will essentially “turn temper tantrums into a mental disorder.”

Changes in Diagnoses of Disorders

In addition to identifying new disorders, the DSM-5 will also make some revisions to existing diagnoses.

One example is Premenstrual dysphoric disorder (PMDD), a condition in which a woman has symptoms of severe depression, irritability, and tension before menstruation. Its symptoms differ from those for Premenstrual syndrome (PMS) because PMDD sufferers experience more severe and debilitating symptoms, one of which includes a mood-related symptom. The DSM-5 will have PMDD listed in Section 2, rather than the appendix, which will make it an official coded diagnosis.

Binge-eating disorder involves rapid food consumption. Essentially people experience episodes where they lose control over their eating, though they do not purge, starve themselves, or exercise excessively. People with binge-eating disorder are often overweight or obese. According to the National Alliance on Mental Illness, binge-eating disorder is the most prevalent eating disorder in America. The DSM-5 will list binge-eating disorder in Section 2, rather than the appendix. It was not characterized formally in the previous Diagnostic and Statistical Manual.

Understanding Mental Health Insurance Coverage

One major cause for patient’s confusion about health insurance is misunderstanding the way insurance companies define things. Insurance broker Katherine Hermes said insurance companies often state and define things differently than the patient would. This is why insurance policies will often include a glossary in policy paperwork.

“Most diagnoses are just labels we use to give structure to something that is occurring,” said licensed mental health counselor Ben Brafman. “Many disorders are labeled in a certain way so insurance companies get paid.”

Brafman said it should take between six months to a year to get a genuine diagnosis for disorders such as skin picking, hoarding, and binge eating, but the nature of health care and insurance doesn’t allow for that.

“Many clinicians only treat the behavior of what you can see, the skin picking or the eating habits, but the real therapy comes from calming the thoughts and the beliefs associated with why the behavior occurs in the first place,” he said.

Pre-existing Conditions

Loosely defined, a pre-existing condition is any sickness or condition diagnosed prior to a patient applying for health care coverage. The terms of pre-existing conditions can vary from company to company and are often found in the fine print of an insurance policy.

“Most of us think if we already have the condition and the policy is new, the condition pre-dates the policy making it a pre-existing condition,” Hermes said. “With health insurance, your pre-existing condition only counts against you when you had the condition and at the same time did not have health insurance coverage for a set time, often 63 days.”

Before purchasing mental health insurance, it would be prudent for patients to get information on any pre-existing condition clauses.

“The key is understanding that having a diagnosis only counts against you if you have no medical history for the insurance company to draw upon,” Hermes said. “The insurance company uses your claims history to determine your rate.”

Patients who go uninsured for long periods of time will have a hole in their claims history. In order for the insurance companies to protect themselves from excessive claims early in a policyholder’s contract term, if there is a gap in coverage, insurance companies may choose not to cover claims for a certain period of time (waiting period). Typically, after a patient has paid into the system for a specified period of time — usually six to 12 months — insurance companies will begin covering the patient’s claims.

Seeing a Specialist

Sometimes mental health patients may be required or may desire to see a specialist. Some plans require pre-approval or a referral to see a specialist. This can get tricky.

Some insurance plans limit how many approvals a provider can offer in a given time frame. Hermes provided the following example: a provider is allowed to offer 1,000 referrals for every 5,000 patients each month. If the provider only gives 700 referrals in that time frame, they may be given a bonus for controlling costs. On the flip side, if the provider gives 1,300 referrals in that same time frame, there may be a penalty imposed upon him or her.

“The takeaway here is even if a patient has been refused a referral before, there is no harm in asking again,” Hermes said. “One month the provider may have been up against his or her limits and another month, he or she may have more flexibility in their allowances.”

Coding

Medical coding is the process of transforming descriptions of medical diagnoses and diseases into numeric or alphanumeric codes. Coding is extremely important for mental health professionals as well as mental health patients.

If a code changes or is input incorrectly, a patient might be denied a claim that should have been paid, Hermes said. One glitch can be detrimental. There are trained professionals who attend ‘billing and coding’ classes and earn certifications each year.

Though coders strive to keep up with all the changes, patients should also learn the codes themselves to make sure their insurance company covers the code and that mental health professionals use the correct codes. This will increase the chances of the claims getting paid.

Mental Health Coverage After Release of DSM-5

Once the DSM-5 is released, it will certainly change the way mental health patients are diagnosed, how they are treated, and the way their insurance is handled.

“We’re heading into uncharted territory with the DSM-5,” Brafman said. “Everything seems to be in the DSM as a legitimate diagnosis — even some of what I believe is avoidant behavior.”

Experts have said the goal of DSM-5 is to lead to more accurate diagnoses and more effective treatment for mental health disorders.

“The DSM needs to remain a guide for skilled clinicians to help explain, predict, and treat mental illness,” Brafman said. “We’ll have to see how these new diagnoses will be used.”

If the DSM-5’s purpose holds true, it could mean major headway for mental health patients and some of the obstacles they face with diagnosing their mental illnesses and receiving the proper treatment for them.

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