Before Retreat Premier Addiction Treatment Centers accepted its first patient in Lancaster County, Pa., in August 2011, CEO Peter Schorr had made up his mind: His new venture was going to work with insurers as an in-network provider.
Many in the field might consider it a risk, but Schorr says he felt going in-network was actually the safe bet.
“This was a conscious decision I made before we opened,” says Schorr, a 36-year veteran of the addiction treatment field. “One of the reasons is, obviously, it opens up your market much more broadly, and you can take many more patients. The reimbursement is less than out-of-network benefits, but the reward is that you do have a much larger pool to grab from among those who have contracted insurance.”
As providers are plagued by the unknowns of being out-of-network—when they will receive reimbursement or how much—going in-network could become an advantage for many within the field who seek sustainability through reliable reimbursement.
While in-network providers can receive lower payments from insurers than those out of network, contracts negotiated with insurers reliably deliver the expected payments for specified treatment. Bill for agreed upon services, receive agreed upon reimbursement. It’s a model that stabilizes budgets and helps providers map out strategies to sustain their businesses.
Making the cut
An estimated 38 million people in the United States had access to behavioral healthcare and benefits through their health plans as of 2014, according to a whitepaper published in 2016 by America’s Health Insurance Plans (AHIP), an advocacy group for health insurers. For their part, insurers say they are actively trying to bring more behavioral healthcare providers into their networks, but haven’t always found treatment centers willing to participate.
“Health plans regularly assess the adequacy of their provider networks to ensure that members have timely access to behavioral healthcare while accepted metrics are used to track and improve patients’ outcomes,” says Cathryn Donaldson, AHIP director of communications. “However, there is a well-documented national shortage of behavioral health providers, coupled with many behavioral health clinicians who refuse to participate in health plan networks, resulting in patients having to pay out-of-pocket for treatment or forgo it altogether.”
Still, even for Retreat and other willing providers, the path to going in-network isn’t always smooth. Overcoming that hurdle comes down to having the ability to prove your value and demonstrate the delivery of successful outcomes. Insurers seek providers with a track record in evidence-based practices and those who take a holistic and coordinated approach to care, Donaldson says.
“Some plans have created behavioral health homes and are leveraging patient-centered medical homes to ensure more integrated care,” she says. “Others are embedding behavioral health providers in primary care doctors’ offices to help identify these conditions and improve outcomes.”
However, Donaldson says, readily available information on the quality of facilities is significantly lacking, including data on patient outcomes.
“Overall quality measurement for even the more common behavioral conditions is less well developed than for comparable general medical conditions,” she says.
In its efforts to align with insurers, Retreat has found success by illustrating its competitive differentiators and by hosting insurers on-site to demonstrate its programs, at both its Lancaster County facility as well as its second location in Palm Beach, Fla., which opened in June 2016.
“It wasn’t something made up or pulled out of the air,” Schorr says of Retreat’s programming. “We showed proof of what we’re doing and how we’re doing it.”
Operating in network
Providers and insurers alike say they are invested in achieving successful outcomes, but exactly which party is the driving force behind improving the standard of care is a matter of perspective. For example, longer lengths of stay are consistently associated with superior outcomes, however, securing prior authorization for detox and the length of stay necessary for residential patients is oftentimes challenging, Schorr says. And so is advocating for intense residential care rather than outpatient treatment.
“You try to present the case for the patient in front of you,” Schorr says. “A lot of times, insurance companies don’t want to hear it. They’ll give patients a lower level of care to start with. That’s a challenge we have with any insurance company—getting the right amount of treatment time for our patients.”
Schorr points to the example of patients going through opioid withdrawal. Retreat has, on average, been able to secure reimbursement for 22 to 24 days, a victory Schorr chalks up to the organization’s nurses performing utilization reviews and to changing attitudes of insurers.
“It’s kind of a battle on educating people where behavioral health and substance abuse are a small part of the insurance industry, and there hasn’t been a lot of focus on it over the years,” he says. “But now, the opioid epidemic is so out in the forefront in the news all the time, they’re starting to look at things differently.”