Seeking treatment for addiction recovery can be a financial challenge for families and the question on many people’s minds is, does my insurance cover this alcohol or drug treatment program? The good news is that with recent Healthcare reform, treatment for alcohol treatment or drug treatment with insurance is more accessible to insured persons.
Insurance companies are prohibited from applying a lower level of coverage for alcohol treatment or drug treatment within a members plan; they must cover these services at the same coverage levels as all other areas in the plan. However, insurance companies (payers) have specific medical necessity criteria that must be met in order for services to be covered. Medical necessity is the clinical demonstration of medical need for services as defined by each insurance company; payers create their medical policies based on what has been clinically proven to work.
For instance, if you have a headache you are going to try over-the-counter pain relievers before you would consider going to the doctor for a clinical assessment. If you do go to the doctor, he/she is going to try prescription medications before they would consider referring you for brain imaging. These medical necessity criteria are outlined in policies by the payer and indicate what must be done before a higher or lower level of care will be approved or recommended. As well, there are many different treatment models to choose from, and knowing which services will be covered can be tricky unless you know how medical necessity is evaluated and what questions to ask your insurance company.
Not all treatment centers accept insurance as the primary or sole payment source and as such they may require the initial month of service to be paid in full pending assessment of the plans payment. Treatment centers refer to this process as an “Insurance Reimbursement” agreement. In an out-patient treatment setting, insurance companies only cover the specific time periods where the member is being “treated” and do not cover room and board, transportation and/or meals. Additionally, claims payment is largely dependent on the member being personally committed to his/her recovery i.e., continually meeting the payers’ medical necessity criteria.
Payers employ therapists, physicians and psychiatrists to perform concurrent reviews (a regular review of all clinical information between both parties)in partnership with the treatment facilities own clinical staff; this team of payer clinicians will typically have experience in the field of Substance Abuse and recovery that is born from years of practice in their chosen area of expertise. They, along with the treatment facilities clinical staff, will assess each person individually against payer medical necessity criteria, the personalized treatment plan, and the persons medical history to determine if the treatment plan will be effective for the person. If the person seeking treatment does not demonstrate that he/she is engaged in their treatment, as visualized through clinical treatment documentation, the payer can deny further coverage.
For example, Susie Client came to treatment for alcohol treatment and drug treatment at the insistence of her family. She is insured and her insurance authorized an initial stay of 10-days treatment with further days being dependent on a concurrent review. Susie met with her therapist and created a treatment plan that indicated she would participate daily in group sessions, weekly individual therapy sessions with homework assigned and community meetings. Susie and her therapist created clearly defined goals and a plan to work on Susie’s primary treatment goals. This information was provided to her insurance company during the concurrent review process. When the time came for a review between Susie’s therapist and the insurance company to authorize additional days they asked the following:
Q: Has Susie been attending and participating in her group sessions?
A: Not with consistency; group notes indicate a lack of participation and Susie’s continued glorification of her substance abuse history.
Q: Has Susie been completing the homework assignments given by her therapist?
A: No, Susie had several excuses as to why she had not done her homework, all of which centered on her being “forced” to come to treatment.
Q. Has Susie met any of her goals within the initial period of treatment?
A. No, Susie made it clear she was being “forced” into treatment and that she was just biding her time until she got out.
Result: The insurance company denied additional days stating that the client did not have a personal plan for recovery nor had her attendance been indicative of her commitment to her recovery.
Most people do not understand how intimate the concurrent review process is, the payers clinical staff become very involved with the programs clinical team. Understanding the depth of concurrent reviews with the insurance plan can help you manage your expectations for insurance payment.
Determining if your plan covers treatment for alcohol treatment or drug treatment can be difficult. To determine what your insurance company covers, you can ask the following questions of your payer:
- Does my plan have coverage for Substance Abuse/Drug and Alcohol Abuse?
- Does my plan cover the programming offered by the treatment facility?
- PHP-Partial Hospitalization Program: Not necessarily in a hospital setting, this gives daily individual and group therapy for a minimum of 4 hours a day and up to 5* days a week.
- IOP-Intensive Outpatient Program: This allows for individual and group therapy for a minimum of 3 hours a day and up to 5* days a week.
- OP-Outpatient Program: This allows for individual and/or group therapy services billed by the hour with no minimum hours per day/week.
*Not all plans allow the maximum of 5 days a week; you will need to ask what your plan specifically covers.
- Do I have Out Of Network (OON) benefits in the event the treatment facility is not contracted with the payer?
- Are there pre-existing clauses on my plan that would prevent these services from being covered?
At Morningside Recovery, we have a team of billing personnel to take the guesswork out of your coverage for you. We will verify if your plan has benefits for alcohol treatment and/or drug treatment and if you or your loved one enters programming, we work closely with the clinical team to ensure that all pre-certifications are obtained and that documentation is provided timely to the payer to ensure medical necessity is being met on a continual basis. Denials happen but that is not the end of the line for our team; we will appeal medical necessity denials when possible gathering additional information or scheduling peer to peer (Therapist to Therapist) calls when necessary. As well, we communicate with the client, or the family if requested by the client, to keep them up to date on the status of insurance coverage. Morningside Recovery takes pride in obtaining insurance reimbursement for families because we recognize life is stressful enough without adding financial burdens to the issues.
The key to making your insurance work for you when you need it for alcohol treatment or drug treatment is to be informed. You can always feel free to call Morningside Recovery 24 hours a day, 7 days a week at (866) 551-1720 to speak to a skilled counselor.