Category: Health Insurance

Having an effective revenue cycle management in place for your center is essential in optimizing performance and margins. From the first contact with patients, such as verification of benefits and authorization preparation, to efficient service coding and billing, to finalizing and collecting on all claims. 

Throughout the whole process, there are key elements in ensuring success with revenue collections that we will cover in this article. Finding the right people to facilitate and function technology, getting real-time eligibility and service authorizations, using data to build a successful game plan for claims denials. 

Finding the right people to facilitate and function technology: Billers are in high demand now days and technology tools continually advance in ways of making jobs and tasks streamlined and accommodating for centers and their treatment teams, however, you still need people with the ability to use the tools available to them. They have to be able to use those tools effectively while understanding the billing and collection process behind them. Payers advise that we use their online tools to obtain the information we need, so it is very important to utilize those tools available to prevent delays or denials. A solid process and accountability of each person involved, maintenance training, and incentives are all factors in maximizing your revenue cycle management.

Getting real-time eligibility and service authorizations: More than 20% of denied claims are usually caused from an authorization issue. Prioritizing real-time verification of benefits and authorizations has to be the main ingredients to ensure success from beginning to end. Many payers allow the ability to get this information online also, making it even more convenient when you don’t have to call someone and wait on hold forever. Create structured processes, that is frequently updated, for prior authorizations for each payer including any benefit coverages or medically necessity requirements. 

Using data to build a successful game plan for claims denials: The only way to prevent claim denials is to use data from denied claims to improve the process. Understanding the how, why, and what caused claims to be denied, you can adjust accordingly to prevent it from happening again with future claims, resulting in an improved revenue cycle management process. There are cases where it may seem impossible to overturn a denied claim, but if you do your due diligence, respond in a fast and timely manner, there’s a good chance you may surprise yourself. Exhaust all options before archiving denied claims. 

These are just a few ways to possibly help increase your insurance reimbursements for your patients and decrease claim denials. This is so beneficial to everyone involved, from the insurance companies to the staff and treatment team at the center, and most importantly, the patient and their family. 

I would like the opportunity to hear what has worked for your center in the past or present? What obstacles do you frequently run into when dealing with your insurance claims? I look forward to discussing more ways to improve. 

On June 6th, 2019, Anthem, Inc. announced that they are in the definitive stages to acquire Beacon Health Options, Beacon currently serves more than 36 million individuals across all 50 states, and 3 million of those under comprehensive risk-based behavioral programs.

“Our member-focused, integrated clinical care model helps individuals and their families cope with their physical and behavioral health challenges. Together, we will expand access and enhance the quality of care for our mutual members. I am proud of the talented and committed team at Beacon, and we look forward to our future with Anthem.”Russell C.Petrella, Ph.D., Beacon Health Options President and CEO

Anthem didn’t disclose a price it is paying Bain Capital Private Equity and Diamond Castle Holdings for Beacon Health, which is privately held. The acquisition is expected to close in the fourth quarter of 2019. However, this is a great opportunity for Anthem to utilizing Beacon Health Options, already stellar business model, not to forget they are the country’s largest independently held behavioral health provider.

“As Anthem works to improve lives, simplify healthcare and serve as an innovative and valuable partner, we’re focused on providing solutions that address the needs of the whole person,” -Gail K. Boudreaux, President and CEO, Anthem

The acquisition will offer the opportunity to combine both successful business models to diversify the health services and deliver market-leading integrated solutions. Progressing towards a stronger portfolio of specialized services, improved clinical expertise, and ability to offer broader provider networks and establishing positive relationships.

“We are excited to partner with Anthem to serve the behavioral health needs of more than 60 million Americans,” –Russell C. Petrella, Ph.D., Beacon Health Options President and CEO

Once the acquisition is complete Beacon, combined with Anthem’s behavioral health business, will operate as an integrated team within Anthem’s Diversified Business Group. Russell C. Petrella, Ph.D., Beacon Health Options President and CEO, as well as other key members of Beacon’s senior team, will join Anthem’s Diversified Business Group to lead the efforts to offer innovative behavioral health solutions and further expand this business.

“With an extensive track record in behavioral health, Beacon fits well with our strategy to better manage the needs of populations with chronic and complex conditions, and deliver integrated whole health solutions. Together with Beacon, we will enhance our capabilities to serve state partners, health plans and employer groups as they seek to address consumer behavioral health needs.” -Gail K. Boudreaux, President and CEO, Anthem

We are excited and believe this is very significant as more insurers are working on addressing the determinants of care for mental illness that fall outside of the traditional medical care. One out of every five adults suffers from mental illness, and is only increasing, according to the National Institute of Mental Health.

What are your thoughts on this acquisition? Is this good or bad, why so?

Did you know that nearly one out of every five Americans had a mental illness last year? Denying coverage is now being looked at deeper than just a financial issue, as some see it as a human rights issue.

Families are suffering from the strict system placed on behavioral health insurance processes. A system that fails the needs of people who need it the most, because of not meeting insurance company’s, medical necessity, clause.

Without a reasonable doubt, this is more than a concern for so many Americans who suffer from behavioral health illnesses and can’t seem to get the adequate treatment needed to overcome this difficult roadblock.

A psychiatrist once said,

“Before I decided to specialize in psychiatry, I assumed a person in need of mental health care would have the same access to treatment one has for medical conditions like kidney stones, pneumonia or seizures. Instead, mental health patients and their providers face a mountain of bureaucratic obstacles that other patients are spared.”

Imagine being a doctor, and having to tell someone or even a child who desperately needs treatment, that they aren’t considered depressed enough, or their presenting conditions do not meet the most critical states of mental illness in order to be treated.

With adolescent mental health illnesses on the rise, this has to be one of the most ignored issues that we face in America today. According to the new report, diagnoses of “Major Depressive Disorder”,  have risen to over 30 percent since 2013, and now affects an estimated 9 million commercially insured Americans.

Teen depression rates are increasing so rapidly, if we don’t figure out a better solution, we will be headed for an array of consequences. The Centers for Disease Control and Prevention estimates there were 72,000 deaths from opioid overdoses last year and more than 43,000 suicides reported in 2017.

Nowadays the requirement to even be admitted into a psychiatric facility is set so high, it can be very frustrating when attempting to get prior authorization for treatment. Even if patients have just attempted suicide, shockingly many insurers still require prior authorization by phone before they can step foot inside of the facility.

“Even in spite of the fact that we’re in the midst of the biggest public health crisis of our time of overdose and suicide, we as a nation have yet to come to grips with this in the way that it needs to be,” – Former congressman and mental health care advocate Patrick Kennedy. 

For any other medical hospitalization, nothing is really required and the insurers trust the judgment of the providers. Not the same for psychiatric hospitalizations and treatment centers. In the U.S., denials for mental health care occur three times as frequently as denials for general medical care.

The process of finding and funding adequate mental health treatment is a very daunting task, and most times insurers will simply deny treatment initially knowing that most people are going through so much that will won’t challenge denials of care, leaving them feeling lost and confused and only adds to the stress they are already dealing with.

It’s time to make mental health illness a priority in not only fighting the stigma but also the discrimination set forth from the insurance companies. This system continues to get worse and totally does everything they can to stop treating those who need it, simply based on the fact that they are not considered depressed enough, or suicidal enough to please their extreme criteria. Ask yourself, why isn’t mental health illnesses being looked at as serious as cancer, diabetes, or cardiovascular diseases?

It’s quite frustrating when just 10 years ago, a law passed called the  Mental Health Parity and Addiction Equity Act, also known as the Federal Parity Law. The law requires most insurers to cover illnesses of the brain, such as depression or addiction, no more restrictively than they cover illnesses of the body.

“There are still tons of roadblocks on the policy side and, frankly, in spite of the fact Congress thinks they’ve appropriated some gargantuan amount of money, it still represents less than one-fifth of what we were spending on HIV/AIDS during the AIDS crisis when we were losing far fewer people than we’re currently losing today,” – Patrick Kennedy

In a recent study conducted by a private research company and Georgetown University, researchers found the following listed below.

  • Insurers regularly denied coverage to people with pre-existing mental or substance use conditions;
  • Insurers imposed a 20 to 50 percent increase in premiums for people with a history of mental health or substance use conditions;
  • Insurers offered superficial coverage that did not meet essential needs; and
  • Insurers actively created barriers and limited access to mental health and substance use treatment.

The only way we can see any change is by standing up and speaking out on unjust insurance denials and registering a complaint with your health plan. The more we do this, we can help pressure elected officials, insurance commissioners, and the attorneys general to enforce federal and state parity laws in favor of the patients who need the attention and treatment their insurance plan should be covering.

Nothing will ever change if we don’t speak up and hold insurance companies accountable. We must demand equality for those with mental health and addiction challenges. We cannot stand idly by while insurance companies break the law, at the expense of American families.

Help for Mental Illnesses. Get Immediate Help. If you are in crisis and need immediate support or intervention, call, or go the website of the National Suicide Prevention Lifeline (1-800-273-8255). Trained crisis workers are available to talk 24 hours a day, 7 days a week.

Have questions or need help with insurance claims and or denials, we are always here to answer or help in anyway possible.

Billing for IOP in a nutshell

When dealing with IOP billing, there are generally a few more requirements and consistent attention needed to make sure everyone involved is happy. From the patient being able to continue their treatment, to the doctors treating the patient, and of course, making sure the insurance companies are on board with allowing the overall treatment to happen.

Behavioral health levels of care

Behavioral health facilities essentially provide four types of services that insurance companies may consider reimbursement when treating a patient.

  1. Hospital-based inpatient programs, that require medical monitoring, nursing care, and other behavioral health services treated 24/7.
  2. Residential treatment programs, also known as RTC, which is more of a sub-acute facility based monitoring, offering other behavioral health services.
  3. Partial hospital programs, better known as PHP, providing services in an ambulatory setting, and generally requires 20 hours per week.
  4. Intensive outpatient programs, known as IOP, where the patient is provided with behavioral health services for at least 9 to 19 hours a week for adults, and for children and adolescents at least six hours is generally acceptable.

There are so many different modalities and service types when billing for IOP, compared to inpatient and hospital-based programs, which in turn makes it more challenging when trying to get reimbursement.

Similar Article: The Secret To Getting Reimbursed Quicker- Claims Follow Up

Typical services covered in IOPs

If a facility is offering IOP services, they must be licensed at the state level and usually will treat substance abuse and most mental health disorders. Most facilities will set up a weekly schedule for IOP patients, consisting of meeting at least two hours per day, and from three to five days a week.

Typical services generally covered are:

  • Individual psychotherapy
  • Family psychotherapy
  • Group psychotherapy
  • Psycho-educational services
  • Medical monitoring

CMS guidelines required in order for the facility to be eligible for reimbursement for IOP services are:

HCPCS and revenue codes for IOPs

IOP billing codes may differ depending on what the patient’s diagnosis is, and what services are provided primarily either for substance abuse or for mental health issues. Also, another thing to remember when billing for IOP services, if the patient has a dual-diagnosis for both substance abuse and mental health, you can generally only bill for one IOP session per day, even if both were being addressed in therapy. It is always good to document that information for the insurance company, but beware to not submit duplicate claims, as they’ll inevitably get denied and or delay payment.

  • S9480/0905: The per diem outpatient IOP code for psychiatric issues which may include eating disorders, is S9480, and most times is always paired with revenue code 0905. This is generally used for private payers, as Medicare does not recognize these codes.
  • H0015/0906: The per diem outpatient IOP code for all chemical dependency is H0015, and is always paired with revenue code 0906.

Similar Article: 5 Insurance Billing Errors Drug Treatment Centers Can Avoid

Pre-authorization, clinical and IOP all go hand in hand

Just like with all inpatient level care services, most insurance companies require all IOP services obtain a pre-authorization before reimbursement is complete. Although IOP, technically provides only two to three hours per day, most payers require at least 180 minutes of active therapy per day in order to reimburse the per diem rates.

This is why I stated earlier, that clinical documentation is a key element in supporting the full 180 minutes per day, otherwise you’ll end up with a denied claim. A concurrent authorization is generally required to continue to treat the patient and sometimes referred to as short-term interventions, where all clinical and progress of the patient is considered and decided for continued authorization.

We hope this was a helpful and informative article about IOP in particular. If you have any questions about IOP billing and how to maximize your reimbursement for behavioral health services or any other billing concern, please feel free to contact us via email, or check out a ton of extra billing resources here.

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.

“Let us all work together to stop this epidemic from spreading and killing our loved ones.”

As we all know, prescription drug abuse has become an epidemic all across the nation. However, Utah has become one of the nation’s leading states for drug abuse, ranking fifth in the nation for prescription drug overdoses from 2013 to 2015.

Since 2007, the Legislature has passed 101 laws addressing prescription misuse, monitoring prescribing practices, overdose prevention with an emergency drug called naloxone, and court-ordered treatments.

There is also a database known as Utah’s prescription drug monitoring system, which was created in 1995 to assist doctors and law enforcement monitor the use and abuse of prescribed controlled substances. Utah is one of 48 states with a system like this in place, but many other states require law enforcement to obtain a warrant or court order to access the database, however, Utah is not one of them.

In 2012, an average of 21 Utah adults each month died as a result of prescription drug use. Fatal prescription pill overdose is known more commonly in Utah than death by car crash. Most people have the assumption that just because they get prescribed painkillers from a doctor that it is safe to use anytime when in reality this is just not true and can be very fatal.

Since 2002, deaths from prescription pain medication outnumbered heroin & cocaine deaths combined. Nearly half of young adult heroin users reported having first abused prescription opioids. Only 15% of addicts get the treatment they need.

These are alarming facts about prescription drug abuse in Utah, and if you or a loved one is suffering from addiction, please reach out to a treatment center that can help you. There is no better time to get the help you need then now. With awareness and knowledge available nowadays, we can all help stop this horrible epidemic.

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.

reimbursement for wilderness programs

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.

outdoor behavioral councilIt 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.

insurance covered wilderness programs

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.

how to get wilderness programs covered

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.

how wildneress affects drug rehab

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.


The United States is not Star Wars. The Affordable Care Act (Obamacare) is not the Death Star about to blow up, although there is a new hope.

If the ACA stays in-tact (for the most part) premiums will level out.

Why are things looking up?

Insurance carriers’ prospects for the personalized healthcare market – Obamacare – are seemingly as bright as they have been in quite some time – as reported by the the Standard & Poor’s 500 (S&P 500) , Global Ratings analysis.

Multiple carriers for health insurance have begun ending the shocking losses that forced them to increase prices for premiums for the ACA foundation health plans an average of twenty five percent for the upcoming year. The S&P anticipates rates to be far under this level for 2018.

Essentially what the report uncovered was a view of 2017 as rogue single price correction.

The report failed to include what effect that President elect Trump’s promise to get rid of the ACA as soon as possible. 2018 and anything that happens after will be determined on how our governments newly elected leadership decides what to do with Obamacare.

obamacare and mental health

As many experts predicted, Obamacare has faced many challenges and has remained very difficult for carriers to find both fair pricing for Americans and to remain profitable.  The initial demand from those with per-existing conditions as well as those who were more sick than expected threw a big wrench in the overall algorithm for insurers and caused pricing to come in far to low.

Financial losses from Obamacare

There was wide spread financial losses from insurers – as much as $3 billion in 2014 and up to $4.5 billion in 2015. This caused many carriers in the industry to scale way back or just get out of the market entirely.

The obvious course of action was for those carriers still covering coverage to increase premiums and other costs this past year. They also received from help from Obama when he allowed the restrictions to be more stringent for gaining health coverage because of a special circumstance – not during open enrollment (people were figuring out how to enroll only if they needed coverage).

What now?

Losses from the individual market are now expected to come in under $3 billion for this past year and 2017 is projecting to hit the break-even point for many carriers – some could even turn a profit for this market.

What to do for Health Insurance Now

With any change of Presidents there will be a national conversation that begins with a lot of unknowns and speculation involved on what is going to happen to our healthcare system.

With all the Facebook posts, Tweets, Snap chats, blogs, articles, and talking heads… it is easy to get over loaded with info and not know what to do or what to believe.

It is best to understand the facts:

  • No matter what fate is decided for the Affordable Care Act (Obamacare), there is still a law, and it is still in place.
  • Open enrollment for all of our healthcare started on 11/1 and ends on 1/31
  • In order to be covered with health insurance by 1/1, you can’t wait to give it as a gift on Christmas — its gotta be done by 12/15 the previous month.

Like all Americans right now, if you don’t like paying extra taxes for no reason, you will need to get covered by 1/15 to avoid any penalties (it has been like this for years now so get with it!).

If you are covered through a group plan by the folks you work for then power to you, no worries at all in that case.

Sometimes change is good and some time change is bad and sometimes, whelp, change is just change. So things could get different, but not likely any time soon — so most insurance agents (many of them indifferent because they get paid no matter what happens) recommend you sticking with the current rules for now.

insurance billing help

In the end, we all just want to be protected in case something crazy happens like you get sick or ill or need some life saving surgery. For a decent reminder on how to enroll, keep reading.

  1. Every boy scout knows to ALWAYS BE PREPARED.

    Make sure you remind yourself to follow up with your current coverage provider on how to re-up your plan this year. Be diligent with any changes you need to know about as well.Just because you had a great health year last year, doesn’t mean you will have one this year. Speak to your doctor, get your yearly physical, if you need to make any changes make sure your coverage lines up with those health related changes…. Like do you have a big surgery coming up? Maybe it is time to up the premium a bit?
  2. As with any purchase in life, DO YOUR HOMEWORK and ask the right questions.Be proactive here folks – care about yourself, about your health plan – ask questions. One of the best ways to do this is to talk to a broker or agent who represents multiple plans and coverage options. They get paid relatively the same commission by all the insurance companies so it is in their best interest to make you happy and find the right plan that fits your needs.

    Precision health starts with personalized health plans – make sure you find the right one every year.

  3. Do you know what a subsidy is? How about the exceptions for not having coverage.The good thing about the ACA is that it was meant to provide healthcare at an affordable price for every person in the United States. This means that YOU, yes you, maybe entitled to a discount on your premium based on your yearly income. Find out what your tax credit and other out of pocket savings will be by asking your carrier, your agent, or when you apply for new coverage on

Remember the Penalties

Obamacare built in some buffers if something comes up or changes happen and you are unable to obtain or retain coverage for up to 60 days. If you go longer than that allotted time frame, there could be penalties you will owe or additional taxes you have to pay on a household basis.

Thinking of outsourcing the billing and financial aspects of your program?

You may be surprised to know that patients often associate your professional services with things completely removed from obtaining treatment for their addiction or mental health issues.


Does stress or anxiety play a role in seeking help?

Patients report that stress over the cost of services is often a deterrent to seeking help.

mental health billing

When your practice revolves around substance abuse and any presenting mental health issues, adding more emotional stress is counterproductive to obtaining desirable outcomes.


Problems with coding

With the advent of the far more detailed ICD-10 and CPT4 coding, onsite or captive practice  billing departments are often caught between rapid billing to stabilize cash flow and accurate billing to reduce error returns.

That certainly has consequences at the provider level, but perhaps more importantly it creates distrust and tension between providers and patients, as the following example shows.

One woman, who found some $4,200 worth of errors on her medical line items from an drug rehab facility stay after being treated for addiction from an opiates, says that she would have considered the amount of insurance reimbursements before seeking treatment at this particular place.

Now When her primary care provider suggests in-patient testing or a procedure on anything, she first gets at least one more opinion. Seeking the second opinion means weeks could pass before accepting the initial doctor recommendation.

In the meantime, she researches what the procedure or stay at a facility should cost so she can anticipate what her bill will be when her services are provided.


Deductibles and co-pays

Given the higher deductibles many people have these days, the deductible may be all that is charged for the service(s).

In short, her concerns prevent her from getting medical care within a prompt and effective time frame.

If treatment or testing proves unavoidable, she reports feeling tense, anxious and even angry because of the cost – and in her case, high probability of triggering a relapse.

This mentality certainly doesn’t improve her recovery outcomes.

With many patients now subject to deductibles and co-pays ranging in the thousands of dollars, they are more likely than ever to scrutinize their bills.


Mental Health Parity

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) strives to assure that private insurers meet certain criteria to maximize reimbursements for mental health providers.

Comprehensive accounts receivable management starts with accurate verification of benefits (VOB). Verification of Benefits is normally completed within one to two hours, based on the accuracy of information received.


Proper insurance billing practices

Accurate billing for residential substance abuse treatment can relieve your staff of some of the more unpleasant aspects of practice management.

problems with insurance billing

Prompt but accurate substance abuse billing maximizes reimbursement rates, but there will be times when patients fail to pay their share of the costs. It is very important that your staff isn’t the source of unpaid claims that increase the burden on patients and families.  

One of the most important factors affecting inpatient mental health reimbursement is the completion of a thorough intake history.

Identifying concurrent health issues can prevent insurance billing errors. If your practice includes medical as well as behavioral health and addiction recovery services, it is important to identify and separate those secondary and even tertiary diagnoses from one another.

For instance, a patient with substance abuse issues may also suffer from underlying depression as well as physical health issues resulting from addiction.

Incorrectly lumping all of these under one code fails to maximize billable revenue from insurance providers, may result in using up billable days allotted under the mental health guidelines, and may cause insurers to incorrectly reject claims.


Charting errors can be costly within insurance billing

Working across a wide variety of payment platforms, ranging from Medicare and Medicaid through various insurance carriers might generate many potential errors at the time the claim is submitted.

Another area of concern is found with charting errors arising from electronic medical records (EMR). Some of these commonly used in the behavioral health world include BestNotes, Accumed, HIPPAcrm, and others.

The advent of EMR was meant to provide continuity in patient histories, but it has also resulted in significant charting errors.

As noted in this Chris Dimick article available on the AHIMA website, copy and paste, aka “carry forward” charting errors can significantly impact both care and reimbursement outcomes.

While drug rehab insurance billing does not take the place of regularly scheduled chart audits, it may be easier for a detached third party to catch repetitive charting errors simply because they are not intimately involved in daily patient care.


Be diligent!!

To recap, accurate insurance billing and/or practice management removes some of the stressors that affect positive patient outcomes.
It also improves employee and staff morale, creating a positive experience all around.