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Insurance warriors fight for coverage

December 23, 2015
by Jill Sederstrom
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Battling insurance companies is a universal fight for most behavioral healthcare providers, whether residential or outpatient. But providers that go the extra mile to help patients benefit from their coverage plans say persistence and determination pay off.

“I see our team as insurance warriors,” says Dale Maugans, MA, director of client financial services at Harmony Foundation, a residential drug and alcohol addiction recover center in Estes Park, Colo. “They are warriors. They are advocates in establishing reasons why the client has to be at this level of care.”

The 30-day treatment program has an average of 20 to 22 covered days for each client, but this average hasn't come easily. Harmony Foundation has created an entire team of administrators whose job is to pursue insurance approval for the patients they serve. The work begins before the patients arrive with the client benefit team checking on benefits as soon as a person shows interest in entering the program.

Lauri Winslow, the client benefits team leader, says it’s important to be transparent and upfront with patients about what their insurance company says it’s willing to cover and what costs could potentially fall to the patient.

“We have to figure out if they are out-of-network, which most of our patients are. We have to try to figure out what amount they may or may not get reimbursed,” Winslow says. “We are advocating for the client, trying to let them know if the insurer will authorize all 30 days while they are here, and let them know ‘this is what you might get back.’”

Once the patient arrives, the case management team takes over to begin work on the precertification or preauthorization.

Electronic health records

Using data from Harmony’s integrated electronic system, the team is able to share information gathered during the intake interview along with vitals and blood alcohol count. Additionally, Clinical Opiate Withdrawal Scale scores or Clinical Institute Withdrawal Assessment for Alcohol scores can support the reason why a patient needs the center's services.

Maugans says after the precertification is complete, the team continues to work with insurance companies on reviews to advocate for medical necessity throughout the patient's stay.

“That's when it gets gutsy,” she says. “We have to establish a reason why somebody has to be in a 24/7 level of care. I want to say insurance companies are almost generous in giving detox days, but once they move out of that kind of acute level of care, that's when it's very tricky.”

To gain coverage, the team does what Maugans refers to as detective work, using information from counselors, group sessions and the on-site physician, which is available in the electronic system, along with information on the patient's past history. Using this information, the team creates a case for each patient that includes what brought the patient into treatment, the patient's triggers and how he or she has been doing since starting treatment.

“We appeal every unapproved day and that includes speaking with the insurer’s doctors, their outside companies that they hire to review the cases, and even after the client leaves, sending in their chart with another letter of appeal,” Maugans says.

In some cases, Maugans and her team are able to establish medical necessity for the patient to be in residential care by providing data to insurers about the patient's past failed attempts at lower levels of care; using the geography of the state to establish that the outpatient options are too geographically distant for the patient to travel each day; advocating for care during critical times such as holidays or weekends when admittance to outpatient facilities may not be possible; or highlighting potential dangers in a home environment.

“They don't want to set them up to have maybe a few days of sobriety and go home to an environment where substances are being used, where there are children around,” Maugans says.

The center also has an on-site medical center, so patients with other health issues might be able to receive less costly care at Harmony than they could at an acute care hospital.

Whole person care

Maugans recommends that providers establish medical necessity by moving beyond just the biological data and instead look at the whole person.

“Understand that it's a struggle, embrace the struggle, and get as much varied information as possible. Remember that they are looking for bio, psycho and social information,” she says, adding that if a provider isn't able to get enough wide ranging information from electronic data, they can meet with the client to ask direct questions.

Maugans acknowledges the job can be frustrating at times, so the team might boost morale with friendly competitions to see who can get the most covered days authorized or offer debriefing sessions for employees who might have had a particularly rough day.

Payer issues

Residential facilities aren't the only providers that face insurance challenges. Anelia Shaheed, associate at the law office of Julie Allison in Florida, represents substance and mental health providers in all levels of care to resolve payer issues. She says one of the easiest things providers can do to fight for reimbursement or coverage of services is join together with other behavioral healthcare providers to address what they perceive as unfair practices or requirements.

“It's much easier to negotiate with power versus a single operator,” Shaheed says. “Insurance companies are businesses just like our providers are, so if something makes business sense for them, they will do it. And I've seen success with that. But they will not do it if it's one guy who is a drop in the bucket, and they know they have the power to say no to him.”




I have worked in the health insurance industry for a decade, on the "other side" of the fence from treatment programs like this one. Here is my experience--facilities like this have an expectation that all people would benefit from a set number of treatment days, in this case, 30. This expectation is not based on any clinical evidence, nor does it accommodate the unique needs and preferences of patients. Some patients need more or less depending on their social circumstances, use history, etc. Instead of trying to squeeze insurance companies for 30 days of treatment, their focus should be on building a quality program that follows ASAM and other evidence-based treatment protocols. That is what insurers want to authorize.