Insurance coverage for mental health treatment is important for most people in choosing a program, however it can be confusing and challenging to understand.

Here are some things we have learned that might be helpful to you. Keep in mind these are not set in stone, as the most important variable in getting reimbursement is the insurance plan you are enrolled in. Note that these benefits can vary significantly even within the carrier and plan you have.  

Most insurance companies pay for a given number of days at each level of care, based on you meeting medical necessity for care for their different diagnoses. This is documented carefully by treatment programs to justify ongoing care. With some companies, additional days can be approved based on you meeting medical necessity during that time, and the program providing appropriate documented care.

How It Works When You Decide To Enroll At a Treatment Program

One of the first steps when you talk to an admissions person or submit an application is to get a
VOB, or Verification of Benefits. 

A VOB is a confirmation that the insurance coverage is active and lets you know if the policy includes coverage for mental health treatment. 

Along with the VOB some providers will also receive a conservative estimate of what your insurance plan will likely provide to reimburse treatment that meets their criteria of care. This report is typically generated by an Insurance Billing Company contracted with a treatment program, or the insurer’s own in-house insurance billing department. It is based on an average of hundreds or thousands of actual payments to treatment programs providing care for you or your loved one’s specific issues.  

Factors considered include not only the insurance company and policy you have, but also your diagnosis. This is a good faith estimate, not a guarantee, and it’s not a report that is generated by the treatment program you are looking into, unless they do in-house billing, as not all do this. The program’s admissions team can typically answer most of the questions you may have, but may need to get additional information from the insurance company when needed.

In-Network Insurance Plan

If a treatment program is in-network with an insurance company, the program has agreed to accept full payment for services provided, and these rates are not negotiable.  Sometimes added services can be billed separately, like psychological testing for example, depending on your plan. There will typically be a yearly deductible, an out of pocket minimum, that must be paid by you before these benefits will begin paying.  

The main benefit of an in-network program is that the majority of costs are covered by the insurance company. The main drawback is that the level and type of care tends to be standardized by the programs, both to meet the requirements of the insurance company, and also save the program money since there is no financial benefit for them to provide extra services.

Single Case Agreement

If the treatment program you are considering is not in-network with your insurance company, in most cases, we can only try for what is called a single case agreement (SCA) if the policy has NO out of network benefits.  If you do have out of network benefits, the insurance company tries to steer you to use those benefits, versus an SCA. 

The rates of reimbursement can vary significantly from the payments provided for in-network plans. The insurance biller negotiates for higher rates of return, based on a) the level and type of services provided, and b) you meeting medical necessity for that level of care.  

This estimate accompanies theVOB you receive prior to treatment. At Corner Canyon the VOBs we submit take up to 24 hours to get the information returned. This allows you to use that financial information as part of your decision about which program is best for you or your loved one. 

The main benefit of single-case agreements is that significantly higher rates of reimbursement are possible, based on added services, which allows the program to provide care that costs more. This care can include advanced treatment options such as more highly trained and qualified personnel, more thorough assessment, holistic care that is not typically covered, a higher quality living environment, and food, among many other possible benefits.  

The main drawback is the added complexity of negotiating for these higher rates of reimbursement. So  the expertise and experience of the insurance biller used by a program can make a difference in the amount received.  Again, this is reflected in the VOB.  Corner Canyon splits this cost with clients, and it is usually 7-8% of the total collected, depending on the amount collected.  

Different Rates Of Reimbursement For Levels Of Care

Most insurance companies pay a certain percentage of the billed rate for each level of care, which can include 

• In-Patient Hospitalization (usually a psychiatric hospital setting)
• In-Patient Residential Treatment (highest level of care at Corner Canyon Health Centers) 
• Partial Hospitalization PHP  (therapy groups that are provided during the day and may or may not be In-Patient)
• Intensive Outpatient IOP (fewer hours of group therapy, and it may occur at night to accommodate you if you work)
• General Outpatient (OP), which is typically just one therapy session a week and occasional other services.

Note:

Insurance companies now often try to push clients to lower levels of care, which cost them less.  Good insurance billers, good documentation by the program, and medical necessity are all factors that play into getting more days approved at the level of care clients need for  treatment.