- Financially Better for Clients. This maybe counterintuitive, but paying out of pocket for many healthcare services has been shown to actually be the same or less expensive. The average number of sessions I see clients in a year is 21. Here’s the math: 21 Sessions x $159/session = $3339. That’s a big chunk of money. But…whatever is not reimbursable to you by insurance is often tax deductible. Most healthcare expenses can also be paid directly with an HSA or FSA. Additionally, more and more families are choosing high deductible, lower fee plans. Pay $5000 deductible and then insurance kicks in. That’s after you’ve paid your $833/month.
- Less Complication. It takes longer to verify insurance, verify their plan covers my services and ensure they can be seen It is a fact that every document or form that needs to be sent to insurance is an opportunity for them to avoid financial responsibility. I’ve had dozens of situations where my office manager would send in a form and the insurance company would first claim they never got it. We’d resend it. Then they claimed it was not completed correctly. Resend after corrections. Then they would claim it was incomplete. This game can last up to a year (I’m still getting payments from insurance claims filed over a year ago).
- Clinical Decisions are Not Driven By Insurance. I’ve had way too many instances where an insurance company told me or the family that the client ‘no longer met criteria for services.’ What? How the heck would they know that? It’s based on the number of sessions they allot, the diagnosis I gave and how much money has been spent. At no time does insurance actually review my notes, talk to the client or family or inquire about the clinical status. No thanks – I don’t want insurance professionals making decisions for my clients. And just in case you were thinking it, I’m not a right-wing, libertarian nut job. This is actually my progressive, liberal side coming out advocating for my clients against huge companies whose sole business model is to take in as much money as possible and avoid contractual obligations.
- Flexibity. No insurance company has ever liked hearing that I’m on-call for clients and use texting, video chat, etc. to continue treatment and support between sessions. They also are not fans of me working with parents in a consulting manner. They don’t want to hear that I provide insider knowledge of treatment programs. None of this fits within their narrow definition of what a counselor should do. I do what is necessary to create stability and promote a healthier life.
- Protection. Until there are safeguards that protect clients from being blacklisted for a preexisting condition (ACA is currently under attack from the Trump administration for this) I’d prefer not be forced by insurance companies to diagnose a client. For me to get payment, I have to provide client’s name, diagnosis code, CPT code (what service I provided), my license information, and my NPI (national identifier for healthcare professionals). If I fail to provide any of that, the claim with be denied. In my opinion, there is no reason why a company needs evidence that a client has a diagnosible condition. I totally understand requiring all the other information but diagnosis is unnecessary. At times, a diagnosis is important for the client or family to hear and understand.
This is our second installment on how to get insurance to pay for residential treatment and therapeutic programs. Below is some great information to help you beat the insurance companies at their own game. Insurance companies count on your ignorance, laziness and distractibility to avoid paying for services they are legally obligated to cover.
With the Affordable Healthcare Act and the Mental Health Parity Act in full swing it’s time to learn how to get the most out of the insurance you pay for. We’ve included some tricks, strategies and how-to’s to help you out. Though we’re focusing on Residential Treatment for our discussion here, this info is applicable to therapeutic programs like wilderness programs, therapeutic boarding schools and intensive outpatient programs.
Ok, let’s get started with some basics…
What If I Need Additional Help?
First, read through everything below. These strategies are time consuming and require steady attention but they are not impossible. If you still don’t feel confident in holding your insurer accountable, contact us for a free consult and we’ll help you figure out how to move forward.
What is the Insurance Company’s Criteria for Residential Treatment?
…Or more importantly, how does an insurer define residential treatment? Each insurer has their own definition but most have virtually identical criteria. For our purposes, residential treatment is defined as specialized mental, behavioral health or substance abuse treatment that occurs in a residential (overnight) treatment center where the provider is responsible for clinical service, safety, shelter, and food.
Licensure differs by state, but these facilities are typically designated either as residential, subacute, or intermediate care facilities and may occur in care systems that provide multiple levels of care. Residential treatment is 24 hours per day and often requires a minimum of one physician (or psychiatrist) visit per week in a facility based setting.
What Specific Criteria Do They Look For?
Now, let’s drill down a bit more and look at some of the more common criteria requirements insurance companies are looking for when determining whether to pay for residential treatment to a struggling teen or young adult.
- Was there a sincere attempt to first use evidence-based outpatient therapy in the home community by a licensed professional before residential treatment was requested and outpatient therapy did not work? Basically, they want evidence that you tried outpatient therapy with weekly sessions (or more often) and because it was not effective, a more intensive level of care like residential treatment was justified.
- Prior to admission, did you contact your health plan for list of in-network residential treatment options? More on this later – what to do if you can not find a good option.
- Is there uncontrollable risk-taking to self or others or other dangerous behavior?
- Has there been a documentable and rapid decrease in level of functioning in one or more life domains. Another way to describe it is a decline in functioning resulting in the ability to perform self-care.
- Is there a likelihood of no improvement in current environment (ie. home or college)
- Is there a reasonable expectation that patient will improve in residential setting and be able to return to outpatient therapy for aftercare?
How to Request this Higher Level of Care?
Now that you understand the criteria, let’s talk about how to actually request residential treatment.
- Write a letter strongly recommending admission to residential treatment
- Provide copies of assessments and testing performed by a licensed professional that indicate 1) a formal diagnosis and 2) specific recommendations that list residential treatment.
- Explain how outpatient therapy has not been successful
- Explain why current circumstances make it unlikely that patient will show improvement (ie. Improvement is not likely in home setting due to social stressors such as negative peers that sell drugs but remain in the environment)
- Document unsafe, declining behaviors – show symptoms and behaviors that represent a decline from usual state and include either self-injurious or risk-taking behavior that cannot be managed outside of 24 hr care. Can your kid maintain abstinence outside of 24 hr care?
- Explain that the residential treatment program uses evidence-based clinical interventions.
- Request the residential treatment program directly contact your insurer for pre-authorization. Pre-authorization is the insurance company’s way of giving formal permission to use a higher (and more expensive) level of care. Make sure to obtain the tracking number and verification of the call from the residential treatment program. If approved, obtain written authorization confirming admission approval.
After you send off your request, your insurer should should respond in 5 days. Don’t wait that long – call them every day to find out the status of your request. Yes, seriously – call every day.
Accepted! Now Some Additional Insurance Mandates
The insurance company accepted your request (more below on what happens when they do not accept it) and a wave of relief comes over you planning for some quiet time once your kid is safely transitioned. But before you get too comfy, there are a few things you want to make sure the residential treatment program will do to ensure insurance covers as much as possible. It’s easier to ask these questions during the admissions process rather than at discharge. Here’s a list of what to look for or ask for:
- A basic physical during admission (urine screening for drug facility)
- Onsite nursing and 24hr access to med care
- Multidisciplinary assessment (also called a Biopsychosocial Intake) performed within 72 hr of admission, including information obtained from patient’s previous providers (ie. therapist, primary care physician)
- Individual therapy with a licensed therapist (ie. LPC, LCSW, LMFT) at least one time per week
- Weekly meetings with doctor for medication management
- Weekly family therapy
- Discharge plan created one week after admission which acts as a set of exit criteria
- Licensed in the state in which they are located. Some facilities are owned by huge companies in another state. Make sure they are credentialed and licensed.
Denied. Now on to The Appeal Process
Denials are just a way of life in the therapeutic treatment world but it’s certainly not the end. Here are some information on what to do when you experience a denial.
- First Thing – Do not let the denial get you mad and do not attempt to use logic, common sense or science to understand why. Insurance is a business and their business model is take in money and pay for as little service as possible – period.
- If residential treatment is verbally denied, request written denial. They must deny in writing and often will send the residential treatment program as well as the insured person a copy.
- Do not just ignore the denial and send your kid off unless you are willing to pay out of pocket and work your tail off at discharge to get the insurer to pay for it.
- How to appeal depends upon the reason for denial. The insurance company will likely list specific criteria either your kid or the residential treatment program did not meet.
- If the insurer states that residential treatment is not a covered benefit but they offer other mental/behavioral health benefits, they are required by law to pay. In Harlick v Blue Cross of California – On August 26, 2011 the court confirmed that California’s Mental Health Parity Act requires health plans to provide coverage of “all medically necessary treatment” for “severe mental illnesses” under “the same financial terms as those applied to physical illnesses,” and are obligated to pay for residential treatment for people with eating disorders even if the policy excludes residential treatment.
And It’s Still Denied – What Next?
If you submit an appeal with additional information and site the law but still are denied or hear nothing, you can request an independent review from your state’s regulatory body that oversees insurance compliance. It’s amazing how quickly insurance companies can ‘find missing paperwork’ or reverse a denial when regulators and attorney’s get involved.
- Send a certified-mail cover letter describing the dispute
- Provide all relevant evaluations, assessments and testing you already sent to the insurer
- Submit a doctor’s letter stating care is medically necessary
- You can also hire an attorney that specializes in insurance issues like this. They are often worth their specialist price tag.
Plan B – If You Can Afford It
If residential is denied and you don’t want to push the insurer for whatever reason, you can pay out of pocket for room and board and try to get the clinical services covered. This approach is often what is equivalent to out-of-network coverage. The insurer is more likely to cover outpatient therapy, group therapy and medication management (virtually the same as if client was living at home and going to therapy).
You can also request that the residential treatment primary therapist get a single case agreement which forces the insurer to pay at in-network rate and you only owe the copay, as usual.
What if Our Family Member is at Therapeutic Boarding School?
With the growth of therapeutic boarding schools, we’ve received a ton of questions about how insurance pays for the clinical aspects of these hybrid programs. Here are some tricks we’ve picked up over the years:
- Think like the insurance company – they want to hear your son or daughter is being referred to as a patient and not a student.
- Make sure to request a physical assessment is done at admissions. This promotes the perspective that he/she is a patient and not a student. Remember – we want the insurer to understand this is a therapeutic program, not as much an academic program.
- We also want to ensure the program is keeping daily records such as treatment plan updates, nursing and medical notes and service notes – health plans will want copies. We want to be documenting progress as well as setbacks.
When we conduct placement services, we always request the therapeutic program develop a treatment plan with some specific exit criteria. The first day of treatment is the first day of discharge planning. Some plans will want exit criteria so err on the side of having the program provide it early on. It’s also a good clinical practice to give the providers a clear target.
In Which State Should Insurance Regulators Be Notified if Insurance Refuses to Cooperate?
The state in which treatment is being provided is where insurance regulators should be contacted if your insurance company refuses to play nicely. The state in which you live may be where your insurance is attached, but legal oversight for provision of service and insurance regulation is in the treatment state.
Can Insurance Pay for Services Retroactively?
Theoretically, yes. Practically, it’s pretty difficult and will require regular attention and contact with the insurer. They will likely ‘lose’ applications, claim forms and anything else you send. If you get insurance to agree to pay for residential treatment or other therapeutic services after treatment has started, you can request for retroactive coverage. It’s best to write a letter (and send it certified mail and keep a copy for your records) stating why you didn’t understand or it was not stated clearly in a policy that treatment was covered.
Will Insurance Cover Partial Hospitalization Programs (PHP)?
Partial Hospitalization Programs or PHPs is typically a level of care designed for individuals who need structured mental health, behavioral health or substance abuse programming but do not need 24-hour supervision (ie. inpatient or hosplitalization). Many hospitals and residential treatment programs offer partial hospitalization or day treatment services. Good PHPs are designed to provide support, education, medical monitoring and accountability during the hours of the day often identified as most troublesome for patients. Patients participate in therapeutic groups, structured activities and discharge planning similar to those offered in the inpatient and residential programs. Many patients who have been in an inpatient or residential program can “step down” to this level of care because it continues to provide a high amount of structure and support.
Insurance generally covers PHP at a per diem rate (daily rate) but will not cover overnight which the hospital or treatment program may charge extra for. Make sure to clearly understand how the treatment center charges for PHP before signing up. Also make sure insurance covers it and what portion it covers.
So we covered several of the topics and tricks that can help you navigate the insurance company maze when it comes to paying for residential treatment. If you need additional help, contact us today – firstname.lastname@example.org
Today we examine some of the basic differences and similarities between therapeutic boarding schools and residential treatment centers (or programs).
THERAPEUTIC BOARDING SCHOOLS
Also known as Emotional Growth Boarding School (not used so much any more), is a boarding school based on the therapeutic community model that offers an educational program together with specialized structure and supervision for students with psychological, behavioral, substance abuse, or learning difficulties. Another newer term is Academy which lends some gravitas and impressions of legacy. Basically, it sounds fancier.
In contrast with Residential Treatment Centers, which are more clinically focused and primarily provide Behavior therapy and treatment for adolescents with serious issues, the focus of a TBS is toward emotional and academic realignment involving clinical and academic oversight for physical, emotional, behavioral, family, social, intellectual and academic development. Therapeutic and educational approaches vary greatly; with the approaches best described as a combination of interventions often based on the founders’ perspective. The typical duration of student enrollment in a TBS range from one to two years with many schools mandating a minimum stay of at least 1 year. Students may receive either high school diplomas or credits for transfer to other secondary schools. Some therapeutic boarding schools hold educational accreditation within their respective states. TBS’s may be for-profit or non-profit entities and might also be owned by a much larger company (eg. Aspen Education Group, Red Cliff Ascent, Universal Health Services to name a few).
Therapeutic boarding schools are generally middle schools and high schools that have comprehensive therapeutic interventions (medication management, individual/group counseling, life skills) for the students and a program to help them with self-esteem and problem behaviors. Some are more therapeutic than others while some boarding schools are actually therapeutic but will not list themselves in that category to avoid any negative connotation.
Most of the therapeutic boarding schools do not have a medical plan for bipolar disorder, and do not provide psychiatrists on staff. If you want your child to attend a therapeutic boarding school he or she needs to be stable enough to attend school with therapy support (typically includes individual counseling 1-2x/wk, group counseling 1-2x/wk and 1 weekly phone conference with parents/therapist), while maintaining a relationship with an outside psychiatrist. Additionally, some schools do not wish to administer psychotropic meds. Ask the admissions folks if this is something important for you.
Sometimes the school that best meets the child’s needs just doesn’t exist anywhere near home, or the child may become too unstable to stay at home and attend school. It may become painfully obvious that a change in environment with a twenty-four-hour peer group and non-parental authority figures may help the child grow and mature in a safe environment. Maybe they are a danger to themselves or others and they need to be in a setting that can monitor their illness and behavior, as well as provide them with tools to understand and deal with their illness while not losing ground in school.
Residential Treatment Centers (RTCs) are medical facilities (most of the time). They should have psychiatrists and nurses on staff. They administer medications, make medication adjustments, and provide therapy and schooling. They are required to follow a student’s IEP.
Residential schools can cost anywhere from $56,000 to over $125,00 per year. A school district may pay part or most of the fee of such a placement, but typically only after a due process hearing. This process is not recommended for parents – Definitely bring in professional support for this (yes, a case manager or educational consultant with expertise in IEP/504 process and laws within your state).
If you have not noticed the theme, here it is – Parents should ask for help from a clinical case manager or educational consultant. While the vetting and application may seem like an easy project for accomplished parents, the timing, financial and clinical complexities can create significant challenges. The case manager should have any professionals working with your child contribute to the discussion on placement strategies and options. Leave this to the professionals. It costs money on the front end but will save you thousands of dollars over months and years and also help you to understand your child, family and the education/psychological process much better.
Here are some additional resources: