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Large part of my business is dealing mental health reimbursement problems. People with some problems that can be treated with therapy and medication is manageable.  The real problem is with severe conditions where daily supervision and guidance needed. The two most common issues  are mental health problems, and  or substance abuse.

The Affordable Care Act gave us a false hope that mental health and substance abuse treatment will be covered under the insurance policies. The false hope is arriving from the insurance administration of this care.  While the benefit is available it comes with managed care. Most expensive services require insurance prior approval. Many of the inpatient residential treatment facilities are not in network and have no idea, nor interest, to obtain prior authorization.  So, under the Affordable Care Act we have the coverage, but the law left it to the insurance companies to deny care.

Two parties, the residential treatment facility and the insurance company, supposed to work together are very far away from each other.  Most of these facilities are set up for cash payments and generally don’t participate, nor understand medical insurance.  In the other side insurance companies routinely deny care in out of network residential treatment facilities.

The major factor in treating mental illness is learning to make life changes.  Most insurance company denials state that services could have been provided in an Intensive Outpatient Program. That is almost always a false statement. Major life changes involves the patient relocation and close 24/7 supervision.  It cannot be done while living home and attending a daily sessions.

The usual story is that a parent takes a young adult child to a facility in remote location.  This is an effort from the parent to save that child from further harming him or herself, with a hope for recovery and healing.

In most cases the effort pays off. A few months later this young adult find a new direction is life.  They learn to cope with the illness, or give up illegal drugs. It can be a combined problem; mental illness brought on by drug use.

The  problem is the price tag of  about 40-60 thousand.  Most people expect the insurance company to pay for most of the bill.  Instead it becomes  a tag of war between  the facility’s inability to bill to the insurance company correctly and the insurance company wanting proper billing submission. Once that mess settles the next state is the insurance denial.  The majority of these denials states that the care could have been provided in an Intensive Outpatient Program.  We all know that is not true, but it is a good start to avoid payment as far as the insurance company concerns.

Fighting these denials after-the-services is nearly impossible.  Of course there are a few exceptions where additional considerations may help to overturn those denials.

The best course of action is to be proactive. Bring this person to the psychiatrist.  Do locate an in network Intensive Outpatient Program and enroll.  If it doesn’t work there is a proof, and very good reason for the residential treatment facility. Even so, do call your insurance and ask if there is an in network residential treatment facility.  It is always a good idea to ask and look and check it out prior treatment.  If there is none then ask for a prior approval to the facility of your choice.  By this time there is a psychiatrist and treatment facility on the record, so it would be very hard to deny.