Category: Health Insurance

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.

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 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.

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.

Insurance 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.

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.

“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.

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.

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.

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.

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?
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.
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 healthcare.gov.

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.

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.

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.

It seems like a no-brainer to keep diligent track of all major incidents that occur with your patients – and it is.

What is often not understood is how important this documentation plays a part in making sure all benefits are getting utilized from insurance carriers.

If your facility has either JCAHO or CARF then you do not have an option when it comes to incident reports. These must be diligently kept in order for you to keep your accreditation. If you are not accredited, this video can give a quick glance on where to start:

An incident report should be filed every time there is something out of the ordinary that happens. This is especially true for mental health and addiction treatment centers – adults and adolescents included.

Although an incident that needs to be reported can set back progress and hinder treatment, it also has a good chance of triggering a patients behavioral health benefits to kick in. Knowing how each incident potentially plays into one of your patients getting access to key benefits in their insurance policy can play a huge part in a successful outcome from treatment.

Reporting incidents in drug treatment programs or adolescent behavioral health facilities can provide a number of benefits:

Proper reporting can show gaps in processes and opportunities for program inprovments
They can help identify key needs in staff training, where further continuing education is needed
Helps clinical staff review and adapt care/treatment plans
Can set a benchmark for a clinical team to measure performance against
JCAHO or CARF accreditation requires immaculate record keeping – best to start now
This type of documentation can be an important part of a legal defense – hopefully never needed of course

What are some of the types of incidents you should record?

Death or impending death of a patient
Suicide/homicide attempt
Sexual assault or rape
Physical abuse
Physical harm or threat to self or community
Need for law enforcement, fire station, or medical emergency professionals (ambulance)
A centennial event that would be news worthy
Any possession of a violent or deadly weapon during any level of care
Any violation of an individual’s rights
Admission to hospital because of serious injury or illness
Outbreak in the community of a serious contagious disease

What processes should be set up when an incident occurs?

Connect verbally and in writing (incident report) with clinical team no later than 24 hours after the occurrence.
Key information that cannot be left out: patient name, age, level of care, date, time, location of incident, staff on duty, detailed description of the occurrence, if medical care was needed, and the current status of the patient.
Establish a follow up plan of action and contact any necessary outside sources.
*Establish a quality assurance process to review incidents quarterly.

It is important that both clinical and support staff are aware of the importance of these reports, and that they take time to review them. It is on the management of the facility to make sure both staffs are reporting on timely and consistent basis. This is especially important when your facility relies on insurance billing for substance abuse or behavioral health as a means of revenue. There should be a dedicated point person or email group that your third party insurance billers have access to as well.