Category: Eating Disorders

Insurance carriers all look at eating disorder treatment differently. Submitting claims or billing for eating disorders can be complicated.

Navigating an insurance billing for eating disorders can be a nuisance if you do not know what to do or where to “touch.”  One of the main obstacles to treatment for facilities and outpatient programs helping individuals with eating abnormalities is the cost of the treatment.  Some residential treatment centers can cost up to $30,000 a month. Clearly with everything that has happened in 2020-2021, a crucial driver in where someone chooses to get treatment is the ability to accept insurance as payment.

This makes holding insurance companies accountable to their policies and contracts in terms of reimbursement for those needing help with eating disorders very critical.

This makes holding insurance companies accountable to their policies and contracts in terms of reimbursement for those needing help with eating disorders very critical.

Now, while studies show that early diagnosis and evidence-based medical care approach are both critical for recovery, insurance regulations and guidelines in most cases make it almost impossible to receive the appropriate care needed. 

So, if you or your loved one is faced with this type of condition, where do you start? Sadly, these challenges sometimes include determining how to analyze your insurance plans to understand the treatment coverage that is ideal for you. Here are some aspects that you should know about insurance billing for disorders:

What type of eating disorders are covered by your insurance? Billing for eating disorders varies by insurance carrier.

Many insurance policies have these disorders covered by benefits that technically are dictated by the DSM-5 eating disorder list these eating disorder diagnoses:

  • Binge eating disorder
  • Anorexia nervosa
  • Bulimia Nervosa
  • Avoidant/ restrictive intake disorder
  • EDNOS Splits Up
  • ARFID

What will be deducted and what will be go to the out of pocket max for my insurance, and how much is it?

In most cases, once we make a phone call to the insurance company that we know will make billing for eating disorders as about as tough as any art possible, the admission department or the respective department will check the benefits. After the confirmation, we will be informed of any deductible that is supposed to pay out of pocket. This is usually the amount that is supposed to pay before an insurance company covers a claim. The specific amount sometimes varies depending on the insurance company as well as the plan.

how to do billing for eating disorder treatment

For instance, if a deductible is $ 500 and treatment is billed at $ 250 daily, the patient would be responsible for covering the initial two days on their own. After payments are made or the patient meets their deductible, the insurance firm will cover the expenses 100%. Some insurances or actual treatment programs require policyholders to pay co-insurance. This is where the patient is responsible for paying a certain percentage of the entire insurance billing for eating disorders. This can range from 10 to 50%.

What level of care is paid for?

In most cases, the level of care that insurance companies approve for is individual outpatient therapy. The most common process for insurance in terms of level of care, however, of behavioral healthcare is inpatient, then residential care, PHP (Partial Hospital program (PHP), and finally the IOP (intensive outpatient program).  Note that, for anyone to access any of the above treatments, they must:

  • Have benefits under their plan for these levels of healthcare and have out of network coverage is the program is not credentialed as an in-network provider.
  • Meet the necessity, which is evaluated by the severity of symptoms, current weight, vital signs, and blood work results.

How long will the coverage last?

This will depend on various factors. Has the condition improved? Is it deteriorating? Most insurances state in their “insurance billing for eating disorders” policy that according to the ACA almost all have unlimited days, depending on medical necessity. Once medical necessity stops meeting the level of care required for a certain program, insurance  will most certainly require a step down for a less intensive level of care.

For instance, a patient can be admitted into a residential program once stabilized and no longer in need of critical care or is not meeting the clinical or medical criteria. Similarly, if you do not improve in that care, and your condition is worsening, you will be admitted to a better level of care, such as inpatient.

What if insurance does not cover eating disorders?

There are a few things you can do depending on the personal and financial circumstances:

  • Switch plans; This should be pretty straightforward for anybody whose current plan does not cover eating disorders. Not all insurance companies offer this, but some reliable ones do it as a reprieve for members from a high-cost treatment.
  • Some non-profit organizations now partner with various treatment centers to provide financial help to those who cannot afford life-saving treatments. Look for one and ask for help.

It is important to understand these factors so that you can advocate to receive the right treatment. You are capable and strong enough to mastermind your future.

Please text us at 541-ASK-AXIS with any questions!

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

information on insurance billing for mental health and addiction

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.

Supreme Court Ruling on ACA.

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.

Most healthcare facilities treat eating disorders through comprehensive therapeutic programs with an emphasis on continuity of care. PHP and IOP billing for eating disorders can be complicated.

Day treatment programs commonly known as PHPs and IOPs are a popular option because they allow the patient to get sufficient mental and emotional support from a multidisciplinary team of professionals. IOP often involves several hours of treatment, including nutritional counseling, meal support, therapy, and medical supervision.

PHP and IOP Billing pro tips

PHP is another option and is used on patients who do not qualify for inpatient hospitalization but are stable enough to benefit from outpatient treatment. PHP for eating disorders includes weekly sessions with psychiatrists, individual therapy sessions, medical monitoring, nutritional support and planning, guidance on cognitive coping skills and group or family therapy. Insurance billing for eating disorders differs with the type of care.

Insurance Billing for Eating Disorders For PHP

Partial Hospital Programs (PHP) are provided to patients who do not need hospitalization and require the patient to have at least 20 hours of care per week. Some PHP services are provided in ambulatory settings.

PHP billing information

All PHP bills submitted by hospitals should be under one of the four Type of Bill (TOB). Outpatient hospitals, Critical Access Hospitals (CAH), and Community Mental Health Centers (CMHC) have respective codes.

Outpatient can be considered both PHP and IOP

131: admit through discharge

132: interim-first

133: interim-continuing

134: interim-last

CAH

851: admit through discharge

852: interim-first

853: interim-continuing

854: interim-last

CMHC

761: admit through discharge

762: interim-first

763: interim-continuing

764: interim-last

The appropriate healthcare common procedure coding system (HCPCS) code for eating disorders is 90791 or 90792.

Sequential Billing

 Payers require providers to submit PHP claims for continuing treatment in sequence.

  • If the patient completes the treatment in one month, providers should submit bills through TOB codes 131, 851, or 761.
  • If the treatment takes more than one month, the provider should submit claims using TOB codes 132, 852 or 762.
  • If the treatment takes more than two months, the provider should use TOB codes 133, 853 or 763.
  • Providers should use the codes for continuing claims until the last month when they should use TOB 134, 854 or 764.

Tips on PHP and IOP BillingInsurance Billing for PHP and IOP Eating Disorders 

Intensive Outpatient Programs (IOP) is a form of care where adult patients are treated for 9 to 19 hours per week and a minimum of six hours for children. S9480/0905 are the per diem IOP codes for behavioral problems, including eating disorders. This billing code is only used for private payers because Medicare does not recognize it. Further, the following codes can be used if the payer insists:

H2019: therapeutic behavioral services, per 15 minutes

H2020: therapeutic behavioral services per diem

Most payers require pre-authorization for IOP services to qualify for reimbursement. Patients must undergo a minimum o 180 minutes of active therapy to reimburse the provider at the per diem rates. This is why it is very important for providers to have clinical documentation of the full 180-minute session when making IOP bills. Healthcare providers are required to obtain concurrent authorization if they wish to continue treating the patient.

Payers require providers to use the UB-04 claim form specifying the preferred Type of Bill (TOB) and Revenue Codes (RC). The applicable code for eating disorders in TOB 131, RC 0905 and HCPCS code S9480. For Medicaid patients, the provider has to indicate the level of care using a modifier.

Some payers allow independent practitioners to provide IOP services and submit bills using the H2035, which is reimbursed using hourly rates instead of facility rates.

Avoid Duplicate Billing

Healthcare providers should only bill for one type of IOP or PHP service per day even if two or more units or specialists are managing the patient. Submitting duplicate claims often results in denied or delayed reimbursements.

Understanding Insurance Issues For Eating Disorders

Navigating an insurance billing for eating disorders can be a nuisance if you do not know what to do or where to “touch.”  One of the main obstacles to treatment for individuals with eating abnormalities is the cost of the treatment.  Some residential treatment centers can cost up to $30,000 a month! This makes getting insurance reimbursement for people needing help with eating disorders very critical.

Now, while studies show that early diagnosis and evidence-based medical care approach are both critical for recovery, insurance regulations and guidelines in most cases make it almost impossible to receive the appropriate care needed. The treating clinical professionals 

So, if you or your loved one is faced with this type of condition, where do you start? Sadly, these challenges sometimes include determining how to analyze your insurance plans to understand the treatment coverage that is ideal for you. Here are some aspects that you should know about insurance billing for disorders:

What type of eating disorders are covered by your insurance?

Many insurances have eating disorders cover benefits that technically cover these eating disorder diagnoses:

  • Binge eating disorder
  • Anorexia nervosa
  • Bulimia Nervosa
  • Avoidant/ restrictive intake disorder
  • Any other specified eating or feeding disorder.

What will be deducted, and how much is it?

In most cases, once you make a phone call to the company, the admission department or the respective department will check your benefits. After the confirmation, you will be informed of any deductible that you are supposed to pay out of your pocket. This is usually the amount you are supposed to pay before an insurance company covers a claim. The specific amount sometimes varies depending on the insurance company as well as the plan.

For instance, if your deductible is $ 500 and treatment is billed at $ 250 daily, you would be responsible for covering the initial two days on your own. After you make the payments or meet the deductible, the insurance firm will cover the expenses 100 %. Some firms require policyholders to pay co-insurance. This is where you are responsible for paying a certain percentage of the entire insurance billing for eating disorders. This can range from 10 to 50 %.

What level of care is paid for?

In most cases, the level of care that insurance companies approve for is individual outpatient therapy. The best level, however, of behavioral healthcare is inpatient, then residential care, PHP (Partial Hospital program (PHP), and finally the IOP (intensive outpatient program).  Note that, for you to access any of the above treatments, you must

  • Have benefits under your plan for these levels of healthcare
  • Meet the necessity, which is evaluated by the severity of symptoms, current weight, vital signs, and blood work results.

How long will the cover last?

This will depend on various factors. Has your condition improved? Is it deteriorating? Most insurances state in their “insurance billing for eating disorders” policy that you have unlimited days depending on medical necessity. Once you stop meeting the level of care required for a certain program, you will have to step down for a less intensive level of care.

For instance, you can be admitted into a residential program once you stabilize and no longer need critical care or you do not meet the clinical or medical criteria. Similarly, if you do not improve in that care, and your condition is worsening, you will be admitted to a better level of care, such as inpatient.

What if my insurance does not cover eating disorders?

There are a few things you can do depending on your personal and financial circumstances:

  • Switch plans; This should be pretty straightforward for anybody whose current plan does not cover eating disorders. Not all insurance companies offer this, but some reliable ones do it as a reprieve for members from a high-cost treatment.
  • Some non-profit organizations now partner with various treatment centers to provide financial help to those who cannot afford life-saving treatments. Look for one and ask for help.

It is important to understand these factors so that you can advocate to receive the right treatment. You are capable and strong enough to mastermind your future.