Category: Adolescent Behavioral Health

Tech developers are foaming at the mouth trying to address the shortage of psychiatrists and other mental health professionals with something called telepsychiatry!

In a day in age where mental health care is at its highest it has ever been, hospitals, clinics, and treatment facilities are unable to keep up with the demand due to the shortage of mental health professionals, specifically psychiatrists. If that doesn’t grab your attention, experts say that it’s only going to get worse within the next decade.

In California, as of 2013, there was a shortage of 336 psychiatrists and forecasted to reach between 729 and 1,848 by 2025, reported by the national projections from the Health Resources and Services Administration, cited by the state Governor’s Office.

In the Chicago, the St. Bernard Hospital, CEO Charles Holland said its extremely hard to recruit psychiatrists as it expands its mental health services. Three years ago, due to the growing demand, they opened an outpatient mental health clinic and next month will expand its inpatient mental health unit from 40 beds to 60 beds.

“We feel it is an emergency. We feel it’s getting worse.”— Marvin Lindsey, CEO of the Community Behavioral Healthcare Association of Illinois

In 2005, Minnesota depression rates in women living in rural counties were as high as 40 percent, compared to only 13 to 20 percent in urban counties reported by the Department of Health. In more recent years, a report produced by the Minnesota Hospital Association indicated that from 2007 to 2014, there was a 40 percent increase in emergency department use for mental illness encounters in Greater Minnesota, compared to only a 34 percent increase in the Twin Cities.

We can see the demand is here and not stopping from rising higher and higher. So why isn’t there any young, eager students seeking a career in this much-needed industry?

Let’s just be honest, being a procedure-oriented doctor will get a straightforward payoff for fixing a broken arm or leg, rather than a broken heart where psychiatrists know their treatment is more of a lifetime plan.

“There’s no victory lap (in psychiatry) where you can say you fixed that patient, on to the next one,”- Travis Singleton, Senior Vice President of Physician Staffing Firm Merritt Hawkins.

Greater awareness, diminishing stigma and a worsening opioid crisis in America, are making more individuals seek mental and behavioral health care. Meanwhile, nearly 60 percent of psychiatrists are over age 55, fueling a retirement wave that experts say exceeds the pipeline of the new doctors who are expected to fill the limited psychiatric residency slots.

What if I told you, one strategy that has shown effective promise for addressing this shortage is telepsychiatry? What is that exactly? Well, it allows patients to obtain psychiatric services from a provider at a distant location through technology such as video consultations. Brilliant!

In Ector County, Texas, Independent School District Head Nurse Laura Mathew, has utilized this technological advancement to help with students at her school when two years ago, Texas Tech’s Chair of Psychiatry, Dr. Bobby Jain, started a program where students could book telepsychiatry appointments through the school nurse. School nurse Laura Mathew says 70 kids have used the program so far.

“We should never discount the power in our pocket,” -Dr. Thomas Kim, the Austin, Texas-based Internist and Telepsychiatrist

Dr. Kim, also in Texas, has adapted to the new wave of virtual healthcare providers, exchanging the doctor’s office, medical clinic or hospital, for a mobile-based health platform that connects with people wherever they are that need immediate help. This platform has taken high praise in the behavioral health industry, as a fast-growing field in which discreet access to health care has become monumental for improved care, and addressing the shortage of psychiatrists.

“Nowadays we can easily, across a screen, look face-to-face with somebody, and we can do what we normally would do in an office … but then we can also see how that person lives.”- John Sharp, Chief Behavioral Health Officer for MDLive

“As telemental health care gains in popularity, it gives rise to a number of significant legal and regulatory issues, including privacy and security, follow-up care, emergency care, treatment of minors, and reimbursement, among other things,” says Rene Y. Quashie of Cozen O’Connor’s healthcare practice.

“While some federal laws and regulations (such as HIPAA) apply, most of the issues involve state law, which has resulted in an inconsistent patchwork of laws and regulations that vary widely by state. And there are a number of states that don’t address telemental health specifically in their laws.”

In a recent interview, he said, “The nation is starting to turn a corner in understanding the value of telemental health. The technology has improved dramatically. Healthcare providers are starting to realize the value of technology … in deploying the healthcare experience when and where it’s needed.”

With this new technology taking off and only getting better, it’s a great reassurance and significant step towards addressing the shortages we are experiencing in the mental health care industry.

How does Insurance determine Medical Necessity?

Many insurance carriers determine RTC/PHP/IOP authorization for care by utilizing medical necessity criteria to make determinations. The medical necessity criteria applied varies according to the behavioral health service being requested. To determine which criteria set will be used, general examples use the list below:

Level of Care Utilization System (LOCUS) will be used to evaluate behavioral health treatment requests for adults age 19+ years.
Child and Adolescent Level of Care Utilization System (CALOCUS) will be used to evaluate mental health treatment requests for children and adolescents ages 6-18 years.
Early Childhood Service Intensity Instrument (ECSII) will be used to evaluate mental health treatment requests for infants, toddlers and children ages birth through 5 years.
ASAM Criteria will be used to evaluate substance use disorder service and treatment requests
New Directions medical policies apply to the following treatments and services, as applicable:
- Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder (ABA for ASD)
- Applied Behavior Analysis for the Treatment of Down Syndrome (ABA for DS)
- Transcranial Magnetic Stimulation (TMS)
- Electroconvulsive Therapy (ECT)
- Psychological/Neuropsychological Testing (PNT)
- 23-Hour Observation

LOCUS was developed by the American Association of Community Psychiatrists (AACP). CALOCUS was developed by AACP in collaboration with the American Academy of Child and Adolescent Psychiatry (AACAP). Both are maintained by Deerfield Solutions, LLC. ECSII was developed by AACAP. The ASAM Criteria was developed by the American Society of Addiction Medicine. New Directions administers each benefit as designed by the health plan and set out in the member’s benefit agreement. The presence of a specific level of care criteria within a criteria set does not constitute the existence of a specific benefit. Providers and facilities should verify the member’s available benefits online when available, or by contacting the applicable Customer Service department.

Access to LOCUS can be found by clicking here.

Access to CALOCUS can be found by clicking here.

Access to ECSII can be found by clicking on the following links:
ECSII Domains (Handout)
ECSII SI Definitions (Handout)
ESCII Manual 1.1 (Rev 4.2019) – QUICK REFERENCE ANCHOR POINT SHEETS INCLUDED

Access to the ASAM Criteria can be found by clicking here.

Specific policies or criteria set by insurance carriers in 2023. Insurance coverage and criteria can vary significantly depending on the insurance company, the specific plan, and the jurisdiction in which you reside. Insurance carriers often update their policies and criteria regularly.

However, we look can at some general information about the levels of care commonly seen in mental health treatment. These RTC/PHP/IOP levels of care may require varying criteria for insurance coverage:

Outpatient Care: This typically includes individual therapy, group therapy, counseling, and medication management provided on an outpatient basis. Patients may need a mental health diagnosis and recommendation from a healthcare professional to access this level of care.
Intensive Outpatient Program (IOP): IOP offers more structured and intensive treatment than traditional outpatient care. It may involve several hours of therapy and support services each day, usually for several days a week. Insurance carriers may require a mental health diagnosis and a treatment plan from a healthcare professional for coverage.
Partial Hospitalization Program (PHP): PHP provides a higher level of care than IOP. It involves full-day or nearly full-day treatment programs, usually provided in a hospital or specialized facility. PHP may be recommended for individuals who need more support but do not require 24-hour inpatient care. Insurance coverage may require medical necessity criteria and a treatment plan.
Inpatient Hospitalization: This level of care involves round-the-clock treatment in a hospital setting. It is typically reserved for individuals who are in crisis or at risk of harm to themselves or others. Insurance carriers often require a medical necessity determination and authorization for coverage.

The specific criteria for insurance coverage may include other factors for medical necessity, including severity of symptoms, risk of harm, and the recommendations of healthcare professionals.

What is the criteria for medical necessity using LOCUS assessment for RTC/PHP/IOP mental health?

The Level of Care Utilization System (LOCUS) is a tool used to assess the level of care needed for individuals with mental health and substance use disorders. It provides a framework for evaluating the severity of a person’s condition and determining the appropriate level of care, including Residential Treatment Centers (RTC), Partial Hospitalization Programs (PHP), and Intensive Outpatient Programs (IOP). While I can provide a general overview of the LOCUS assessment criteria, please note that the specific criteria and scoring may vary depending on the version and guidelines implemented by different organizations or jurisdictions. It’s always best to refer to the official documentation or guidelines provided by your healthcare provider or insurance carrier.

A look in detail of the LOCUS assessment of six different dimensions

Certainly! The Level of Care Utilization System (LOCUS) assessment evaluates individuals with mental health and substance use disorders across six different dimensions to determine the appropriate level of care. Here’s a detailed explanation of each dimension:

Risk of Harm: This dimension assesses the individual’s risk of harm to themselves or others due to their mental health condition. It considers factors such as the severity of suicidal ideation, presence of self-harm behaviors, risk of aggression, or violence. The assessment may include evaluating the frequency, intensity, and duration of these behaviors. A higher score in this dimension indicates a greater risk of harm and may indicate a need for a more intensive level of care.
Functional Status: This dimension focuses on the individual’s functional abilities and limitations. It evaluates their ability to perform activities of daily living, including self-care, work or school functioning, social functioning, and relationships. Impairments in these areas may indicate the need for a higher level of care. The assessment may consider factors such as the individual’s ability to maintain personal hygiene, manage finances, sustain employment or education, and engage in social interactions.
Medical, Addictive, and Psychiatric Co-Morbidity: This dimension assesses the presence of additional medical conditions, substance use disorders, or co-occurring psychiatric disorders that may impact the individual’s overall functioning and treatment needs. The assessment considers the severity and complexity of these co-morbid conditions, including their impact on physical health, mental health, and substance use. A higher score in this dimension indicates a greater need for comprehensive care that addresses these co-occurring conditions.
Recovery Environment: This dimension evaluates the individual’s living situation, support system, and access to resources that promote recovery. It considers factors such as stable housing, family support, availability of outpatient services, and involvement in the criminal justice system. The assessment examines the quality and stability of the individual’s recovery environment, including the level of support and resources available to them. A higher score in this dimension indicates a more supportive recovery environment and may influence the level of care recommended.
Treatment and Support History: This dimension examines the individual’s history of mental health and substance use treatment. It considers the effectiveness of past interventions, engagement in treatment, and adherence to medication regimens. The assessment may also evaluate the individual’s experience with different treatment modalities, such as therapy, medication management, or residential programs. A comprehensive understanding of the individual’s treatment history helps determine the most appropriate level of care and treatment interventions.
Engagement/Relapse Potential: This dimension assesses the individual’s motivation and ability to engage in treatment and their potential for relapse or non-compliance with recommended treatment. It considers factors such as the individual’s readiness for change, level of motivation, willingness to participate in treatment, and history of relapse or treatment non-compliance. A higher score in this dimension may indicate a need for a more structured and intensive level of care to support engagement and prevent relapse.

Each dimension is scored on a scale ranging from 0 to 4 or 0 to 5, with higher scores indicating a greater level of severity or need for care. The total scores across these dimensions are used to determine the appropriate level of care, such as Residential Treatment Centers (RTC), Partial Hospitalization Programs (PHP), or Intensive Outpatient Programs (IOP).

Specific guidelines and scoring criteria may vary depending on the version and guidelines implemented by different organizations or payers. There are other official LOCUS guidelines available online, or seeking guidance from a healthcare professional familiar with the assessment can help provide the most accurate and up-to-date information regarding the six dimensions of the LOCUS assessment.

A more specific model of what questions the LOCUS assessment requires to complete criteria

While I can provide a general overview of the dimensions assessed in the Level of Care Utilization System (LOCUS) assessment, I don’t have access to the exact questions or specific questionnaires used in the assessment. The LOCUS assessment is typically administered by trained professionals, such as mental health clinicians or care managers, who follow specific guidelines provided by the organization or jurisdiction implementing the assessment.

However, I can outline the general areas of inquiry that are typically covered in each dimension of the LOCUS assessment:

Risk of Harm:

Inquire about suicidal ideation, intent, and plans.
Assess for self-harm behaviors or risk of harm to others.
Explore recent history of aggression or violence.

Functional Status:

Evaluate the individual’s ability to perform activities of daily living, such as personal hygiene, dressing, and eating.
Assess their work or school functioning, including attendance, productivity, and ability to carry out tasks.
Examine social functioning, including relationships, social support, and engagement in social activities.

Medical, Addictive, and Psychiatric Co-Morbidity:

Gather information about any medical conditions or physical health concerns.
Assess the severity and impact of substance use disorders, including patterns of use, dependence, or withdrawal symptoms.
Evaluate the presence and impact of co-occurring psychiatric disorders, such as anxiety, depression, or personality disorders.

Recovery Environment:

Inquire about the individual’s living situation, stability of housing, and availability of a safe and supportive environment.
Assess the presence and quality of social supports, including family, friends, or support groups.
Evaluate the availability of outpatient services and resources that promote recovery, such as transportation or financial assistance.

Treatment and Support History:

Gather information about previous mental health and substance use treatment experiences.
Assess the effectiveness of past interventions and treatments.
Evaluate the individual’s level of engagement and adherence to treatment plans, including medication management.

Engagement/Relapse Potential:

Assess the individual’s motivation and readiness for change.
Evaluate their willingness to participate in treatment and engage in therapeutic activities.
Inquire about the individual’s history of relapse, treatment non-compliance, or difficulty sustaining recovery.

The questions and scoring criteria may vary based on the version and guidelines implemented by different insurance carriers.

A Closer Look at PHP Billing for Behavioral Health Service Providers

America’s mental health problem has been growing steadily over the past few years. As such, more people require mental health services. If your health facility offers partial hospitalization programs to patients under a psychiatrist’s direction, managing the billing process is among the things you should keep in mind.

It’s best to fully understand the PHP billing process since it will be easier for you to process claims. That said, here’s a closer look at PHP billing for behavioral health service providers and why understanding the billing process ensures timely and accurate reimbursement for the services you offer.

What is Partial Hospitalization for Mental Health or Substance Abuse?

Commonly known as PHP, this structured treatment program primarily targets behavioral health patients. It allows patients to continue residing at home while commuting to the treatment facility for up to seven days every week. It’s an alternative to inpatient behavioral health care and more intense than the treatment patients receive in a therapist’s or doctor’s office.

Medicare and most health insurance policies cover part or most costs related to partial hospitalization services. The covered PHP services include:

Individual behavioral training
Occupational therapy that’s part of the treatment program
Support groups
Patients’ training and testing

According to the Affordable Care Act, insurance policies operating out of states that accept federal financial assistance must cover patients’ PHP treatment. However, the companies are allowed to select the forms of treatment to cover.

PHP Billing Requirements

When dealing with PHP billing, it’s best to ensure that all the parties involved get what they want. As a mental health provider, you should get reimbursed on time, while patients ought to continue receiving the treatment they need and deserve.

On their part, insurance companies need to be on board by enabling treatment to continue. There are many modalities when it comes to PHP billing compared to hospital-based and inpatient programs. This makes things challenging when behavioral health service providers try to get reimbursed.

If your facility offers PHP services, it must be licensed both at the federal and state level to treat mental and behavioral health conditions. Besides, the facility should meet these CMS guidelines for it to qualify for reimbursement:

The attending mental health provider must supervise patients at all times
Patients’ initial treatment plans should be adhered to consistently
Your facility should adhere to best practices for behavioral health treatment
The expected treatment time should be stipulated

Revenue Codes for PHP Billing

Generally, PHP billing codes differ according to patients’ diagnoses and the purposes of the treatment being offered. For instance, mental health treatment and substance abuse treatment may get billed differently. Besides, you should keep in mind that when treating patients with a dual diagnosis for both mental health and substance abuse issues, you can only bill for one PHP session per day.

Here is a good quick cheat sheet:

#0913	H0035	Mental health partial hospitalization, treatment, less than 24 hours
#0913	S0201	Substance abuse Partial hospitalization services, less than 24 hours, per diem

It’s good practice to provide all the relevant information to the insurance company to ensure that your claims get processed on time. Besides, avoid submitting duplicate claims because the reimbursement will inevitably be denied or delayed.

Final Thoughts

If you’re a behavioral health service provider and offer PHP to patients, you should understand the PHP billing process. This will go a long way in maximizing your reimbursement for the behavioral health services you provide.

There is a large debate amongst industry professionals on the ability to allow for PHP billing to be done within a residential setting. There are many variables to this depending on how your program is set up and who the carrier is you are working with.

In and out of network issues come into play as well as some insurance companies have loosened guidelines for network vs. non network providers. Be sure to know the right questions to ask when navigating this complex issue. It is not a black and white situation.

When you think of insurance billing, you probably think of some nice sweet receptionist type person in your doctor’s office taking your insurance card before your appointment and charging your co-pay. Technically, this is a type of insurance billing – just not what I am talking about in this blog. There are huge differences when you think medical billing vs. behavioral health billing.

Behavioral health billing compared to medical billing is very different in the fact that medical professionals (like your primary care physician) bill for specific treatments such as:

Office visit
lab test
X-rays
MRI

This billing is pretty simplified and streamlined. However, with mental health/substance abuse facilities, they may bill for therapy, psychological testing along with medical management for the patient – most of the time in “bundled” services and codes for levels of care such as RTC, PHP, and IOP.

What does that include and mean for the patient and mental health professionals? I’ll tell you.

The insurers may have certain regulations and guidelines like:

limiting how long therapy sessions will be,
how many days they’ll pay for,
and may even have a maximum on treatments they’ll even pay for in all.

This, in turn, makes it difficult for mental health professionals to come up with a master plan to treat the patient and also make sure they get reimbursed for services rendered.

Another thing is, It is important for behavioral health providers to know that many insurance carriers and state Medicaid programs will outsource their mental health claims to a third party. This means they use a contracted company to process, manage, and pay claims.

It is important for an inpatient mental health or addiction program to be aware of this when submitting claims. If this is missed, your claims can be sent to the wrong place — and will just be denied and then obviously not paid in a timely manner.

All you have to do is ask who processes the claims when you call provider services. You can do this when you are actually checking benefits for a patient or anytime before you actually submit claims.

This process of billing for behavioral health can get very complicated. One reason is that even when you are calling into the insurance companies (instead of using a web portal), either the customer service representative is not fully trained, or they are unable to give you the correct information and you wind up being transferred to several different departments and representatives. Furthermore, a lot of these call centers are overseas and the connection is not always the best – making the conversation very difficult to understand. Often times there is this weird volume issue where it sounds like the rep is whispering. One way to overcome these issues is to ask for an “onshore representative” or even request speaking with a supervisor to get an honest and helpful customer service experience.

I’ve found many times, some representatives will try and distract from giving you the right information to move forward in the claims process, and keep you in limbo or going in circles. It is almost like perhaps they are trained to do so in order to slow the payment for the claim.

I really don’t know exactly what the issue is when these situations arise, but I do have some ways to get through those walls of confusion. It gets frustrating and always is a good idea to have someone on your side that knows how and what to do in those situations.

As simple as it sounds, always and I repeat..ALWAYS getting a reference number and name of the representatives you speak with, is one of the smartest pieces of information you can get for each and every interaction when calling on claims. Documentation..rules the nation is what I say!

Imagine being on the phone for over hours just for one difficult claim, and you finally speak to someone who makes sense, and you hang up thinking everything ok, just to find out a couple days later that nothing was done, and they have no record of what was discussed. Talk about heartbreaking. So do yourself and everyone else a favor, and just make sure to get that all so important reference number. Trust me, you’ll thank yourself later.

Heaven forbid you’ll have to go through the “Claims Chamber Torture”, and all goes well, it should only take at least 30 days from the when they first receive the claim. In some cases, they can move faster with a quicker turnaround time if everything goes smoothly. But as a general rule, you can expect it to be around 30 days.

For most in-network mental health facilities, they are contracted with insurance companies and cannot bill their patients for any balance after reimbursement is done. This is what is called “balance billing”. They have to accept that rate given and write off the remaining balance. As far as out of network facilities, you can accept the reimbursement and bill the patient whatever balance may be outstanding.

There are so many factors that must be accounted for when billing for mental health services. If you are running into issue after issue when attempting to get reimbursement, you aren’t alone.

There are a number of third-party insurance billing companies who are experts at this and don’t cost you all that much. If you haven’t considered outsourcing your insurance billing processes, maybe it’s time to do so now. With the many options of outsourcing for mental health billing, it is very important to team up with a company that knows what and how things are done when billing.

Reaching out to an outsourcing company and getting an assessment is the first step in building a strong relationship with your practice. In the long run, you’ll find yourself giving all of your focus on your patients where it really matters.

Health insurance carriers have rarely provided coverage for families that chose a wilderness program to help their child.

With higher levels of therapeutic intervention, processes, safety, and now accreditation, the debate about whether insurance should cover outdoor behavioral programming is heating up.

Struggling with either addiction or mental health issues is no matter to be taken lightly for anyone, especially those still in developmental stages. It is widely agreed upon that it takes multiple models and multiple “tries” in order to have a successful outcome after treatment – and this includes wilderness programs.

Wilderness therapy programs can act as a huge resource for those that need it, however they can also use up 30 to 45 days of benefits – even without being billed to the insurance carrier.

Why is 30 to 45 days a big deal?

Because a lot of families have behavioral health benefits with a set number of days allowable for treatment purposes. This means that although these benefits are not being used – the child can be viewed as still “in treatment” or receiving care towards an overall expected recovery time.

Authorization for additional days receiving residential or partial hospitalization treatment will not be approved in such cases.

Wilderness programs and insurance carriers have never really been on the same page – this is just one of many examples showcasing this disconnect.

Does insurance cover wilderness therapy programs?

This seems like a no-brainer right? Any behavioral health or therapeutic program should be covered under the Affordable Care Act’s ten essential health benefits.

Well, it’s not that black and white.

When it comes right down to it, it can be difficult to get insurance carriers to reimburse RTC, PHP, or IOP for wilderness type programs. At the very least, with the help from billing professionals or a seasoned in-house biller, it is possible to get reimbursement for individual, group, and family therapy given by licensed clinical professionals up to about $300 or so per week.

There is progress being made though, things are changing with wilderness care – the Outdoor Behavioral Health Council and variety of national institutions are now accrediting these programs.

Much like residential and outpatient drug rehabs and mental health programs, a set of operations and processes can now be followed in order to standardize treatment. More and more regulation is coming to the once “troubled” outdoor behavioral therapy world. And that is a good thing for the kids attending, the staff, payors, and the programs themselves.

So much progress has been made that a code specific to wilderness therapy has been developed for billing.

It has already been put in place and gives all programs and third party billers a new tool to advocate for proper reimbursement (as with everything in behavioral health – there are no guarantees).

Maybe it is time for insurance companies to start listening to their members – to the needs of their members.

Many families have teens and young adults who need an option a bit less scary than inpatient drug rehab or therapeutic boarding school. A wilderness program can provide a life experience as well as a solution at a potential fraction of the cost of traditional models.

The fight for insurances to cover wilderness.

A new trend is happening – families are starting to sue insurers in order to get wilderness therapy to cover RTC and other higher levels of care. This has only started to happen in 2017 because of how much more safe and effective wilderness programs have become.

Since January, 2016, there have been class actions filed against Cigna, Oxford, Empire Health, and BCBS. Anthem Health out of Kentucky just recently settled a similar suit.

These lawsuits to get insurance to cover wilderness have been filed in Florida, Kentucky, New York, and Utah – mostly stemming from the expansion of the 10 essential benefits to include mental health.

Because insurance carriers determine level of care needed more by the structure of the program and the professional level of the staff than by the physical nature of the buildings, wilderness programs can be set up in a way that they qualify for Partial Hospitalization (PHP), if not Residential Treatment (RTC).

For instance, it is not uncommon for a week in the life of wilderness to include:

4-5 days hiking/learning outdoors skills
Daily academics/reading assignments
Daily group therapy
Weekly family therapy
Weekly visits with a individual psychologist or social worker
On-call medical assistance from a registered nurse or medical doctor (admits get evaluated prior to enrollment in the programs)

The above structure meets all the requirements for many of the major health insurance carriers out there.

Privately paying $500 per day is steep for any sort of treatment.

It is almost unmanageable for any family without the help from your already expensive health insurance. However, this daily rate helps teens and young adults struggling with:

Addiction
Anxiety
Aspergers
Austism
Depression
Eating disorders
Oppositional Defiance Disorder (ODD)
Post Traumatic Stress Disorder (PTSD)
Self Harm
Suicidal thoughts
Traumatic Brain Injuries (TBI)

Because wilderness programs provide such a unique experience and a unique approach to treatment, they can be expensive.

Without help from insurance these programs can be upwards of $20,000 total per stay.

Is residential or transitional treatment needed after wilderness?

Most licensed mental health and substance abuse professionals will tell you that wilderness programs provide an excellent service to the adolescent and even young adult treatment world. They are a great place for a struggling teen to stabilize and to start the path back to a healthy life.

In many cases wilderness is used as a first step in the continuum of care of the overall treatment process – followed by a brief residential stay, then a longer transitional program, and finally on to outpatient and aftercare.

The bottom line is that medical necessity will determine if residential care is needed. Although each insurance carrier has a different definition, here is the basic criteria:

Has there been a failed attempt at a lower level of care in the recent past? Perhaps outpatient has been tried and there have been failed tests. Or perhaps they left a wilderness program before graduating, or left a residential program against medical advice (AMA).
Plain and simple there are zero wilderness programs that are in-network with any provider. If there are no out-of-network benefits or no chance for a single case agreement, then wilderness won’t be an option.
A potential harm to self or others.
Recorded/documented severe change in any variety of daily active functioning – eating, sleeping, socializing, etc.
Constant cycle of inappropriate behavior and negative actions with zero likelihood of change in the existing environment.

Each one of these criteria can be enough to warrant RTC level of care.

RTC level of care does not mean the entire stay is covered, it just means there is an immediate medical need for residential treatment. An average authorization is only 1-14 days (so utilization reviews become very important in continuing coverage).

After each authorization, a utilization review will need to be done with the case manager in order to approve more coverage or determine if a drop in level of care is warranted.

What are the differences in ongoing treatment options after wilderness?

Long-Term Residential Treatment

This is 24 hour a day treatment for at least 3 months in a stand alone facility. These programs are usually set up to allow participants to drop down to a less structured program while they acclimate back into real life.

Generally long-term RTC facilities take a holistic approach and offer a variety of therapeutic models to cater to a large audience. Treatment is not done in a vacuum. What works for one person may not work for another.

Everyday will be completely planned out in advance with a heavy structure and a set number of rules or guidelines to follow.

Short-Term Residential Treatment

It is common for teens or young adults to transition directly to a short term stay in residential care directly after wilderness. These programs are set-up for a quicker 21-45 day stay where stabilization and transition is more of the priority.

Day Treatment with Sober Living (Transitional Treatment)

Transitional treatment programs are a relatively new concept and were started mostly for the young adult world. Residential programs saw a need to slowly move participants back into the real world – often somewhere away from old acquaintances and old triggers.

These programs start after long or short-term residential treatment and can last up to 18 months

Participants attend individual and group therapy throughout the week while living in a sober house or apartment with their peers.

Outpatient Treatment

The final step down in structured treatment with peers – this is the least intense of the programs. This is also the least expensive and should be done after wilderness at the very least in order to avoid relapse and keep participants engaged in their recovery.

Outpatient programs do not always have a set time frame but 16 weeks is the norm. They include further education on addiction and mental health, drug testing, as well as individual and group therapy up to 12 hours a week.

Insurers Have a Legitimate Defense… With an Asterisk

Health care providers do have cause to deny coverage when it comes to outdoor behavioral therapy. Two main points come to mind when putting yourself in the payors shoes:

Take into consideration the cost and benefits of wilderness therapy. Is this one particular program all that is needed for long term recovery?
- What needs to be proven is that it is more likely that this alternative program is going to be the more cost effective than a traditional model or no treatment at all.
There is not a ton of empirically based evidence to suggest this type of treatment works.
- Cigna flat out suggests that wilderness programs are not evidence-based.
- Aetna considers this form of rehab to be at the very most – experimental and investigational. Here is their policy:

Aetna considers alternative medicine interventions medically necessary if they are supported by adequate evidence of safety and effectiveness in the peer-reviewed published medical literature.

* Here is the asterisk: Medical necessity is tricky. It is the embodiment of personalized care. In many ways behavioral health is trailblazing the way to where our Nation’s healthcare is going – Precision Medicine.

Because every individual’s treatment plan must be tailored to them specifically, to their needs and their issues specifically – it becomes difficult to say that all types of behavioral health programs should be covered for everyone with health insurance.

Insurers require preauthorization be done by before any amount of days of treatment will be covered.

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency.

Preauthorization isn’t a promise your health insurance or plan will cover the cost.

If a kid’s medical history and current physiological issues, personality, or substance use disorders are not going to be significantly helped by spending time in the wilderness (as determined by a mental health professional), then why should a health plan throw blanket coverage over all options?

This is how they work with any condition or disease. Treatments must be vetted – there must be a standard set on how, when, and how often treatment takes place along with other interventions if improvement is not being made.

Just take diabetes as an example. There are a variety of medications and interventions done by both the individual and their treatment team to achieve a successful outcome. This holds true in behavioral health as well.

If you are a family looking at a wilderness program for help – or a program thinking of admitting a family and you are hoping to get some sort of insurance reimbursement, then both sides need to take a close look at medical necessity and if there is an argument for this type of treatment.

There is no inherent negative intent for insurance companies to deny coverage.

They simply must act in the best interests of both their members and their shareholders. Sometimes these lines get blurred – or there is just not enough info out there to make the right decision.

Try to keep an open mind and an adjustable perspective when seeking reimbursement and working with health insurance carriers. The behavioral health world is not a science. It is constantly moving and adapting and we are all trying to catch up as quick as possible.

To Summarize Wilderness Treatment and Insurance Benefits

Wilderness programs, also known as wilderness therapy or outdoor behavioral healthcare programs, are therapeutic interventions that combine outdoor activities and group therapy to address behavioral and emotional challenges in individuals, particularly adolescents and young adults. These programs typically take place in natural settings and involve activities such as hiking, camping, and other outdoor adventures.

When it comes to behavioral health insurance benefits, the coverage and reimbursement for wilderness programs can vary depending on several factors:

Insurance Provider: Different insurance companies have their own policies and guidelines regarding coverage for wilderness programs. Some insurance providers may include wilderness therapy as a covered service, while others may not.

Policy Coverage: The specific insurance policy that an individual has will outline the types of behavioral health services that are covered. It is essential to review the policy documentation or contact the insurance provider directly to determine if wilderness therapy is included.

Medical Necessity: Insurance coverage for wilderness programs often depends on whether the treatment is deemed medically necessary. This determination is typically made by a qualified healthcare professional or mental health provider who evaluates the individual’s condition and recommends the program as part of their treatment plan.

Out-of-Network Coverage: Wilderness programs are almost always considered out-of-network services, meaning they are not directly contracted with the insurance company. In such cases, individuals may have to pay for the program upfront and then seek reimbursement from their insurance provider based on their out-of-network benefits.

Pre-authorization and Documentation: Insurance providers may require pre-authorization for wilderness programs, which means obtaining approval from the insurance company before beginning the treatment. Additionally, proper documentation from healthcare professionals, including diagnoses and treatment plans, may be necessary to support the claim for coverage. This can be done retro-actively as well.

It’s important to note that even if a wilderness program is covered by insurance, there may still be limitations or restrictions, such as a maximum number of days or sessions, co-pays, deductibles, or other out-of-pocket expenses. It’s recommended to thoroughly review the insurance policy and consult with the insurance provider to understand the specific coverage and any associated costs.

Overall, the impact of wilderness programs on behavioral health insurance benefits depends on various factors, including the insurance provider, policy coverage, medical necessity, and the individual’s specific circumstances. It is crucial to gather information directly from the insurance company to determine the extent of coverage and potential reimbursement for wilderness therapy.

Get Quicker Access to Payments from UHC/OPTUM… Is this true?

Is this true from UHC?

To speed up payments to your practice, UnitedHealthcare is phasing out paper checks and moving to digital transactions, where not prohibited by law.

You’ll need to choose between two options for receiving payment from UnitedHealthcare – ACH/direct deposit or virtual card payments. Both of these are facilitated by Optum Pay on behalf of UnitedHealthcare.

If your practice/health care organization is already enrolled and receiving claim payments through ACH/direct deposit, there is no action you need to take.

https://www.cmadocs.org/newsroom/news/view/ArticleId/48988/UnitedHealthcare-moving-exclusively-to-electronic-payments

The California Medical Association (CMA) has learned that UnitedHealthcare (UHC direct pay issue) is in the process of discontinuing physician payments via paper checks and will instead require both contracted and non-contracted physicians to receive payment via automated clearinghouse (ACH)/direct deposit or through virtual credit card payments.

The change, first communicated in UHC’s March 2020 Network Bulletin, was originally planned to be rolled out in phases beginning in mid-2020. Due to the COVID-19 pandemic, the rollout of the program was delayed.

UHC has since announced in its August 2020 Network Bulletin that the program will move forward with a phased rollout beginning with its commercial line of business starting in August 2020. UHC Medicare Advantage and Community and State (Medicaid) Plans will follow with rollouts slated for fall 2020 and early 2021.

UHC will be publicizing the change to both contracted and noncontracted physicians, who will be directed to sign up for ACH/direct deposit through Optum Pay or via the UHCprovider.com/payment website. Physicians who do not elect to sign up for ACH/direct deposit will automatically be signed up to receive virtual credit card payments in place of paper checks.

Physicians with questions or concerns, or that need to request a hardship exemption from this policy, should contact their UHC Provider Service Advocate or UHC at (877) 842-3210 for more information.

What is a virtual credit card?

With the virtual credit card (VCC) payment method, payors send credit card payment information and instructions to physicians, who process the payments using standard credit card technology.

This method is beneficial to payors, but costly for physicians. Health plans often receive cash-back incentives from credit card companies for VCC transactions. Meanwhile, VCC payments are subject to transaction and interchange fees, which are borne by the physician practice and can run as high as 5%per transaction for physician practices. Physicians can avoid these interchange fees by enrolling in ACH/direct deposit.

What to do on the UHC direct pay issue?

This all depends on the business set up and values of your institution. This can cause major problems for some programs and be slightly beneficial to others. Below is an exert from the specialty benefits form for UHC:

“I authorize UnitedHealthcare Specialty Benefits to direct the net amount of my benefit payment to be deposited directly by electronic funds transfer and credited to my account as indicated at the financial institution designated below. If any payments made are dated after the date of my death, I hereby authorize and direct the said financial institution on my behalf and on behalf of my executors or administrators to refund any such payments to UnitedHealthcare Specialty Benefits and to charge the same to my account.”

The form does not have all the disclaimers that could possibly affect your group/facility or your providers.

Direct-Deposit-Form-STD-LTD-DI Download

Claims Department
Direct Deposit Agreement
For Payment of Benefit to Financial Institution

Here is what UHC says the benefits are for ACH

Automated Clearing House (ACH) /direct deposit

We recommend ACH because it’s the quickest form of payment available and there are no fees for the service.
Payments can be routed by both the tax ID number (TIN) and National Provider Identifier (NPI) number level.
Enrollment generally takes less than 10 minutes. You will need to provide your current bank account information.
Funds are deposited directly in to your bank account – there are no paper checks or remittance information to lose or misplace.

Here is what UHC says the benefits are for Virtual Card Payment (VCP)

If you don’t enroll in ACH, in most instances you’ll receive a virtual card payment from Optum Pay. VCPs are electronic payments that use credit card technology to process claim payments. There is no requirement to share bank account information.
A 16‐digit, single-use virtual card will be issuedopen_in_new for payment (single or multiple claims). You’ll receive a VCP in the mail; for quicker access, you can view the VCP statement in Document Library.
Each VCP is issued for the full amount of the claim payment. However, VCPs are subject to additional terms and conditions, including fees, between you and your card service processor.
You can enroll in ACH even after receiving a VCP. However, ACH will only apply to future payments and can’t be applied to previous payments.

We can help navigate if this is something that would benefit any behavioral health institution

Find out how insurance billing works for RTC, PHP, IOP substance abuse and mental health.

Insurance Billing 101

What is a clearinghouse?

A clearinghouse is connected to various insurance companies. Our software sends claims to the clearinghouse where they are basically checked (scrubbed). If the claim passes the scrub it is then forwarded to the insurance company or another clearinghouse if our clearinghouse is not connected to the insurance company. (this has to do with security) The insurance company will do 1 of 2 options accept or reject. If accepted the claim will process and return to the clearinghouse with an ERA which will come back to Practice Suite. There are a few exceptions to ERA’s coming back the biggest one BCBS you will probably not see an ERA from them.

The clearinghouse we use with Practice Suite is RelayHealth. They have been bought by Emdeon and they are now known as Change Healthcare. Relay uses a 4 digit CPID NOT a 5 digit payer ID. Even though they are Change they still use the existing Relay structure.

We also use Office Ally and Availity.

Availity is BCBS preferred clearinghouse.

What is a payer ID? CPID (Claim Payer IDentification)?

A payer ID is a routing number, or address. Tells the clearinghouse where to send the claim like a bank sends a check. Emdeon uses 5 digit Payer Id the most common. This is the # that most insurances will give as their payor id. RelayHealth made their own CPID for their system. This is a 4 digit number.

So basically if you put in a 5 digit payer ID in the insurance set up instead of the 4 digit CPID the claim will not go anywhere. It is like trying to cash a check from a bank at a credit union.

Relay has two types of CPID’s for Institutional claims (UB04) and different CPID’s for professional claims HCFA/CMS 1500. Relay has a conversion search engine within their portal to translate payor id to CPID.

What is a UB04?

This is an institutional claim form. (used for facilities our most common claim right now)

The UB-04 form is a form that any institutional provider can use for the billing of medical and mental health claims. The UB-04 uniform billing form is on white standard paper with red ink, which is used by institutional providers for claim billing.

What is a HCFA 1500 (hick fa)? CMS 1500?

This is a professional claim (used for providers, for Florida’s weirdness and UHC IOP and ROP claims).

What is the Healthcare Financing Administration (HCFA) form in Medical Billing?

… The HCFA is paper form, also known as the CMS-1500 form, and the Professional Paper Claim Form, is used for reimbursement from various government insurance plans including Medicare, Medicaid and Tricare.

What is an ERA?

This is an Electronic Remittance Advice. Also known as a Remit or Remittance. It is the electronic form of the Explanation of Benefits (EOB) this tells us how the claim processed.

What is a Revenue Code?

The revenue code tells an insurance company where the procedure was performed.

What is a HCPCS / CPT Code (Hick Picks)?

The Healthcare Common Procedure Coding System (HCPCS, often pronounced by its acronym as “hick picks”) is a set of health care procedure codes based on the American Medical Association’s Current Procedural Terminology (CPT).

What is the difference between HCPCS and CPT?

HCPCS has its own coding guidelines and works hand in hand with CPT. HCPCS includes three separate levels of codes: Level I codes consist of the AMA’s CPT codes and is numeric. Level II codes are the HCPCS alphanumeric code set and primarily include non-physician products, supplies, and procedures not included in CPT.

What is a Type of Bill?

This four-digit alphanumeric code provides three specific pieces of information after a leading zero. CMS ignores the leading zero. This three-digit alphanumeric code gives three specific pieces of information.

First Digit = Leading zero. Ignored by CMS
Second Digit = Type of facility
Third Digit = Type of care
Fourth Digit = Sequence of this bill in this episode of care. Referred to as a “frequency” code

What does ICD 10 CM stand for?

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD–10–CM) is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States.

What is a Revenue Code? Revenue codes tell insurance companies the type of services patients received, the types of supplies used and the department in which services were rendered. For example, a charge for an emergency room visit for urgent care would carry revenue code 0456.

What is ROI?

Release of information (ROI) in healthcare is critical to the quality of the continuity of care provided to the patient. It also plays an important role in billing, reporting, research, and other functions. Many laws and regulations govern how, when, what, and to whom protected health information is released.

How long is an authorization to release information good for?

an expiration date or an expiration event that relates to the individual or the purpose of the use or disclosure. HIPAA does not impose any specific time limit on authorizations. For example, an authorization could state that it is good for 30 days, 90 days or even for 2 years.

What is HIPAA?

HIPAA (Health Insurance Portability and Accountability Act of 1996) is United States legislation that provides data privacy and security provisions for safeguarding medical information.

What kind of personally identifiable health information is protected by HIPAA Privacy Rule?

The Privacy Rule protects all “individually identifiable health information” held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The Privacy Rule calls this information “protected health information (PHI).”

What is considered personal health information?

Protected health information (PHI), also referred to as personal health information, generally refers to demographic information, medical histories, test and laboratory results, mental health conditions, insurance information, and other data that a healthcare professional collects to identify an individual and ..

What is the difference between PII and PHI?

HIPAA uses the term Protected Health Information (PHI) to refer to protected data, but the concept is very similar to the term Personally Identifiable Information (PII), which is used in other compliance regimes. … PHI includes anything used in a medical context that can identify patients, such as: Name.

What penalties can occur by violating HIPAA?

What is the penalty for a HIPAA violation? HIPAA violations are expensive. The penalties for noncompliance are based on the level of negligence and can range from $100 to $50,000 per violation (or per record), with a maximum penalty of $1.5 million per year for violations of an identical provision.

Can you go to jail for HIPAA violation?

Like the HIPAA civil penalties, there are different levels of severity for criminal violations. The minimum penalty is $50,000 and up to one year in jail. Violations committed under false pretenses require a penalty of $100,000 and up to five years in prison.

How can HIPAA violations be prevented?

7 Ways Employees Can Help Prevent HIPAA Violations

Be educated and continually informed. …
Maintain possession of mobile devices. …
Enable encryptions and firewalls. …
Double check that files are correctly stored. …
Properly dispose of paper files. …
Keep anything with patient information out of the public’s eye. …
Use social media wisely.

Definition of demographics: Specific demographic factors which identify and distinguish.

We use several types of demographics:

Facility
Clinical / Medical Director
Patient
Policy holder (can be same as patient)
Insurance company

UBH/Optum discontinuing Out of Network Benefits …and it doesn’t stop at behavioral health services…medical services might be equally affected.

As of July 1, 2021 UBH/Optum has notified some providers about changes to UBH/Optum plans that apparently include, among other changes, the decision to exclude members’ out-of-network benefits for services located outside of the member’s plan’s service area. Notably, a “Fully Insured” plan according to Optum is a plan wherein the insurer pays for the services and the member is not covered by a self-funded employer plan.. The change will apply to medical and behavioral health services. Keep in mind, services are already subject to prior authorization, and this will add one more barrier to a growing number of barriers to care.

The Notice specifically calls out behavioral health exclusions for non-emergent, sub-acute inpatient or outpatient services received at any of the following facilities:

• Alternate Care Facility – PHP or IOP

• Freestanding Facility – Psychiatric or Substance Use

• Residential Treatment Facility – Psychiatric or Substance Use

• Inpatient Rehabilitation Facility – Psychiatric or Substance Use

While the Notice appears to have been directed to in-network (“INN”) providers, the changes we shared above would not affect services provided by INN providers who evidently can continue to admit and treat members of Fully Insured plans regardless of geography. Indeed, the Notice specifically advises INN providers that they may be asked to accept Optum members who are currently at out-of-netowork (“OON”) facilities that will no longer be covered at those facilities once this change in coverage goes into effect.

optum out of network benefits — This Optum decision could lead the way for other carriers to force providers to go in-network

Despite Optum’s couching this change in policy as a “quality and cost-share” issue, it seems more likely to be strictly a cost-cutting measure, particularly given that the change applies only to Fully Insured plans where Optum is “on the hook” for the cost of care, but not to self-funded employer-plans where Optum’s role is only to serve as an administrator of claims that ultimately are paid by the self-funded plans themselves.

Sounds convenient, doesn’t it? It also sounds like a barrier to much needed care.

As for providers, especially in the behavioral health space, they typically are either unable to secure contracts with payors like Optum despite efforts to do so, or they opt to stay out-of network because they do not want to accept the lower reimbursement rates demanded by the major payors when contracting to be an INN provider.

We fear that Optum’s new policy is a violation of Mental Health Parity laws. While on its face the Notice appears to apply to both medical and behavioral care, in practice, there likely will be a disproportionate impact against behavioral health providers, especially residential treatment centers (“RTC’s”).

Comprehensive and accurate mental health coding is vital as behavioral and mental health claims are on the rise.

We frequently find ourselves progressively adapting to learn nuances with each insurer differently to avoid claim delays or denials. Making improvements accordingly helps make the overall patient experience a lot smoother for the facility’s care team, the engagement with the insurer, and of course the patient’s family.

Nowadays, entities like behavioral health facilities are far more prone to denials and payer audits more than any other medical coverage a patient may have. This puts mental health services at risk as the insurers concentrate on the coding accuracy and things like the duration of services rendered.

The insurance carriers are all about its utilization. They perform plenty of data mining, so all mental health providers regardless what profession they are like psychotherapist, licensed clinical social worker, physician, licensed mental health counselor, or non-physician practitioner, all require that documentation be accurate to avoid delay or denial of claims.

What are CPT codes?

For those who are reading this and not familiar with how claims are paid, they all start with a medical code that can be billable to the insurance carriers.

CPT (Current Procedural Terminology) codes are extremely important and are used for payment for services, especially when it is to be reimbursed by the insurance companies. The American Medical Association developed the CPT codes and assigned from surgical to diagnostic codes for medical providers to use for their patients.

What type of documentation do insurance carriers want to see from providers to avoid any scrutiny?

Patient’s diagnosis. This is critical as the insurance carriers use this information to determine if therapy is medically necessary and if the specific therapy type is warranted. For instance, insurers may question the validity of therapy sessions provided to a patient with a neurological or cognitive deficit or a chronic brain injury when a drug intervention may be more appropriate.
Therapy type. Physicians likely provide supportive therapy while other mental health providers may provide an array of options, for example, cognitive behavioral therapy, psychoanalysis, or insight-oriented therapy. This is important when initially verifying coverage and benefits, and specifying therapy type, facility, etc… to ensure it will be a billable service provided.
Therapy goals: What treatment plans are set in place for the patient, short and long term?
Progress reports: Is the therapy being provided benefiting the patient?
Duration of sessions: What is the therapy start and stop times, to the exact minute.

How to know what psychotherapy codes to use?

As of 2013, CPT codes distinguishes between physician and non-physician providers performing psychotherapy services. Physician and Non-physician providers doing psychotherapy services use CPT codes such as 90832, 90836, or 90837, but all are based on the duration of the session. Aside from coding these services accurately, they should always be accompanied with documentation supporting the time spent providing the psychotherapy service.

Coding tips when billing for mental health services.

Clearly document the time spent and benefits of the psychotherapy. The carriers want to see that a physician billing for psychotherapy is actually doing a therapeutic intervention. Spending extra time talking with the patient does not translate to a billable psychotherapy service. Generally, insurance carriers are worried about over-use of psychotherapy services, particularly if it appears the patient gets no benefit or shows no progress. If in some cases the patient is resistant to psychotherapy interventions or is not taking sessions to heart, it’s not going to benefit them.
Documentation justifies any sessions extending beyond 45 minutes. The carriers want to see and know why time extension was necessary. Without proper supporting documents, claims may receive lower reimbursement or even denial.
Use group therapy (CPT code 90853), when appropriate. Group therapy is great for patients because they can meet and talk with others with similar problems and usually looked at as very beneficial. Carriers may also consider patients who go through bereavement counseling during a public tragedy or for a court-ordered group setting counseling session for whatever reason valid to use this code.

Documents that are compliant and accurate coding helps providers in avoiding delays and denials. Staying up to date with best practices seems to be a never-ending task, however, we are glad we could share some insight with you about the significance of correctly utilizing CPT codes when billing for mental health services.

Here’s what the Supreme Court’s ACA Ruling Means for Addiction Treatment Centers

On 17th June 2021, the Supreme Court ruled in favor of the Affordable Care Act (ACA), dismissing the challenge that the ACA is unconstitutional.

Since it was signed into law, the ACA, widely known as the health reform law or Obamacare, has allowed nearly 31 million Americans to access healthcare coverage.

Besides banning insurers from basing health coverage on people’s pre-existing conditions, the law prohibited insurance providers from imposing lifetime or annual caps on benefits while also placing limits on yearly out-of-pocket spending.

One of the greatly felt impacts brought about by Obamacare is the comprehensive healthcare plans, which allows people with mental health conditions and substance abuse disorders to access healthcare coverage just like other people.

Over the last four years, some changes have been made to the health care reform law, but the new administration is now reversing some of them.

To help you understand the impact that the Supreme Court ruling has on addiction treatment centers, I’ve covered everything from ACA’s impact on substance abuse to billing and reimbursement requirements for addiction treatment centers.

Knowing that their policies will cover the need for this higher level of care and future care is critical for all who need mental health services. Taking away any stigma with any mental health disease is important knowing that some if not all of the cost can be shared by the insurance policy they pay for monthly.

As well as knowing the fact the SCOTUS has upheld Obamacare time and time again shows how important the issue is and will be going into the future for more families and individuals who suffer from the mental health dilema day in and day out

Additionally, we shall see the potential impact this ruling has on the demand for treatment of behavioral health conditions and whether or not it will influence reimbursement rates for behavioral health.

This is the 3rd and 4th attempt to strike down the law which provides coverage for this dire need of insurance coverage for many of the millions of Americans who are stricken with mental health issues.

As time goes on the insurance industry will adapt and find a usual and customary reimbursement rate for providers and insurance policy holders alike but know that this mandated coverage has been deemed worthy and constitutional by the supreme court of law.

Earlier Changes Made to ACA

Since its implementation in March 2010, The Affordable Care Act had survived two earlier Supreme Court challenges. However, the law has also seen several changes during the last administration. Below is an overview of some of the biggest amendments made.

Elimination of the Individual Mandate

When ACA was passed into law, all US residents were required to have health insurance or pay a given penalty. This mandate was designed to have everyone, including the more healthy people to enter the health insurance market. Similarly, it helped keep the ACA premium policies low. A 2017 tax overhaul legislation reduced the penalty for not having a health plan to $0. In December 2018, following the tax overhaul, a Texas federal judge ruled that the $ 0 penalty, by law, is no longer a tax, but a command, hence declaring the whole ACA unconstitutional. The case then moved to Supreme Court, and a ruling was made in favor of the ACA on 17th June 2021.

Work Requirements Added to Medicaid

After the ACA Medicaid expansion was adopted, the federal government required states to have Medicaid beneficiaries prove that they either go to school or work. This change was highly politicized, and hundreds of thousands of Americans, including those with substance abuse disorders, were expected to lose their healthcare coverage.

The Ending of Cost-Sharing Reduction Subsidies to Insurance Providers

In 2017, the federal government stopped paying subsidies to insurers, which was seen as a critical element in motivating these companies to keep premiums down. This change disproportionately affected individuals and families who are not eligible for subsidies.

Expansion of Short-Term Plans

Under the initial ACA, short-term insurance that didn’t provide essential benefits was limited to not more than three months. However, in 2019, the federal government extended this duration to 364 days with the option to renew for three years. Since these health care plans are non-comprehensive, they do not fully protect individuals in severe health conditions.

Slashed Budgets for HealthCare.gov Sign-Ups

Initially, the ACA had navigator programs with allocated budgets to help drive the healthcare sign-up campaigns. In 2017, these budgets were slashed, and the net impact was slowed and depressed enrollment. In the following year, the uninsured rates for US residents rose to 8.5% or 27.5 million people (the highest since the ACA went into effect) not having any healthcare plan at any point in 2018. This translated to more people, including those with pre-existing conditions not accessing medical care.

The Impact That ACA Has on Substance Abuse Treatment

The Affordable Care Act made it possible for people with pre-existing conditions such as drug and alcohol addiction to be accepted by insurance providers. At the same time, the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) mandated all insurers to offer the same level of coverage for substance abuse and mental health treatment as for regular medical care.

Now that the Supreme Court has spared ACA, patients receiving alcohol and drug recovery treatments have been relieved of the stress of covering all the rehab costs. Moving forward, rehab patients will continue to benefit from the covered rehab expenses. That said, here are the four ways ACA will continue to keep inpatient and outpatient rehab treatment costs affordable.

Drug and Alcohol Addiction Treatment Remains a Priority: The ACA considers substance abuse disorders as one of the ten elements of essential health benefits. That means Medicaid and other forms of healthcare coverage sold via Health insurance Exchanges should cover services for substance abuse.
Greater Access to Healthcare: More people will continue to sign up and access medical coverage through the expansion of Medicaid and other low-cost insurance plans. Similarly, states accepting federal aid allocated by the ACA will expand Medicaid coverage to individuals and families living below and slightly above the pre-determined federal poverty line.
Young Adults Will Remain on Parent’s Health Plan: Individuals up to the age of 26 will continue to receive coverage under their parent’s health insurance coverage. According to a SAMHSA survey, nearly 7% of young adults in the US between 18 and 25 have a substance disorder. By extrapolation, more young adults will continue to benefit from covered rehab expenses under the ACA.
Free Screenings and Referrals: If the ACA were ruled unconstitutional, patients with Medicare, Medicaid, or plans under the Health Insurance Marketplaces would have been charged for mental health and alcohol screenings. Now that the law is intact, these services come with no cost for insured individuals.

Billing and Reimbursement for Behavioral Health Service Providers

Now that you know everything about the Affordable Care Act, from the changes made to what to expect moving forward, let’s look at the other side of the ACA – i.e., what it takes for behavioral health service providers to be reimbursed by insurance companies.

Typically, there are four service categories that insurers may consider for reimbursements. These include:

Hospital-Based and Residential Inpatient Care

Hospital-based care and residential programs, widely known as RTC, are acute and sub-acute recovery centers offering nursing care, medical monitoring, and behavioral-health services 24/7. Services provided by these programs are reimbursed on a standardized per-diem basis. Here, the per-diem rate includes all services offered in the program from the accommodation, lab fee, therapies, services of licensed professionals and counselors, dietitians, psychiatric nurses, etc.

Partial Hospital Programs (PHP)

Here, services are offered in an ambulatory setting and require a minimum of 20 hours per week. Billing is done per diem basis, and reimbursement is made on the lesser charges, including services from social workers, addiction counselors, occupational therapists, addiction counselors, etc.

Intensive Outpatient Programs (IOP)

These programs provide patients with behavioral health services for 9 to 19 hours per week for adults and at least 6 hours for children and adolescents. Billing for IOP is cumbersome compared to hospital-based and inpatient programs; hence, it’s challenging to get reimbursement.

Services offered by IOP include family, group, and individual psychotherapy, medical monitoring, and psycho-education. To be eligible for reimbursement, IOP providers must:

Supervise the patient at all times.
Adhere and be consistent with the initial treatment plan
Address the diagnosis that required admission.
Provide enough IOP care to patients for about 12 to 16 weeks.
Be consistent with clinical best practices.

Other Key Takeaways

Due to the Supreme Court ruling, enrollment for healthcare plans will probably rise, and more people with substance abuse disorders will be seeking specialized treatments. It’s therefore fair to conclude that to a given extent, the demand for treatment services for behavioral health conditions will increase.

As far as reimbursement is concerned, the current rates are significantly lower than those for other medical and surgical treatments, and this has led to a lower network of behavioral health providers participating in healthcare plans. If this were to be resolved, health plans would need to raise reimbursement rates. But even then, it would be very costly to try and level up with what behavioral health providers charge patients who pay out-of-pocket. And while there are no official plans to raise reimbursements yet, efforts to boost these rates will be highly beneficial.

Last but not least, addiction treatment centers that accept Obamacare, Medicare, and Medicaid plans should prepare to help more patients access quality care. They should also keep up with the CMS billing requirements to ensure compliance and minimize delays of reimbursements which could otherwise hurt service delivery.