America is halfway through 2021 and the pandemic is finally beginning to wane. The substance use treatment ecosystem is about to be overwhelmed. Overwhelmed.

No one disagrees that many who have been out of work or quarantined due to the coronavirus have turned to substances to deal with anxiety, depression or pain. The anticipated result is that the amount of people seeking treatment for substance use treatment is going to increase dramatically. What does that mean for your organization?

Health plans understand that this onslaught of patients seeking substance use treatment is going to increase their costs. Increased costs due to more people seeking treatment and due to ancillary services, i.e., laboratory costs. I will say it because no one ever does, health plans view substance use treatment and other mental health treatment with disdain.

The health plan disdain leads to unfortunate policies that negatively impact access, reimbursement, as well as definitions of medical necessity. Our industry is under attack. Plain and simple.

The major issues affecting our industry are the following:

• Ever-Changing Health Plans
• Complicated Reimbursement Models
• Increasing Claim Denials Due to Payer Corporate Policies
• Focus Upon Evidence-Based Treatment
• Insufficient Clinical Documentation
• More Lawsuits on Both Sides

Below is an analysis of each issue:

Ever-Changing Health Plans

UnitedHealthcare/Optum recently announced effective July 1, 2021, that all fully insured subscribers can only seek treatment within their state. Simply stated, a subscriber can only seek treatment in the home state where the policy was issued. For those treatment centers that have a large percentage of patients from neighboring states, now you must determine whether the policy is a fully insured policy before admission. If it is a fully insured policy, your organization will not get reimbursed.

For a fully insured plan the employer pays a certain amount each month (the premium) to the health insurance company. In return, the insurance company covers the costs of the employees' healthcare.  This is the type of plan most small employers and many consumers have for their healthcare. Yet, UnitedHealthcare wants to limit who the patient can seek by geography.

UnitedHealthcare is the second domino to fall. They are attempting to change the definition of out-of-network to a limited “area of coverage” defined by the health plan. This substantially decreases access for subscribers to out-of-network providers. Some independent Blue Cross Blue Shield plans implemented this over a year ago. Please note if the provider is in-network this limitation does not apply.

The UnitedHealthcare situation highlights what our industry is experiencing, ever-changing health plans; new policies, new rules, rules that conflict with your licensing authority. All directed at out-of-network providers to force them           in-network at rates driven by the payer. For out-of-network payers this affects whether your claims will be reimbursed. Worse, these ever-changing policies can lead to pre-payment or post-payment review by a payer, which can be a nightmare.

Complicated Reimbursement Models

The plan document, or Certificate of Coverage (COC), is the contract between the subscriber and the payer. The language in many plan documents is disadvantageous to the subscriber and ultimately to the provider. Here is an example of reimbursement policy from two plan documents I recently reviewed:

We develop our reimbursement policy guidelines in accordance with one or more of the following methodologies:

As shown in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS).

As reported by generally recognized professionals or publications.

As used for Medicare.

As determined by medical staff and outside medical consultants pursuant to other appropriate sources.

Another payer plan document and COC indicated this:

Maximum Reimbursable Charge is determined based on the lesser of the provider’s normal charge for a similar service or supply; or a percentage of a schedule that we have developed that is based upon a methodology similar to a methodology utilized by Medicare to determine the allowable fee for similar services within the geographic market. In some cases, a Medicare based schedule will not be used and the Maximum Reimbursable Charge for covered services is determined based on the lesser of:

• the provider’s normal charge for a similar service or supply; or
• the 80th percentile of charges made by providers of such service or supply in the geographic area where it is received as compiled in a database selected by the insurance company.

These plan documents allow the insurance company to have free reign to determine reimbursement. Whatever is the lowest reimbursement possible is what the patient and provider will receive. Please note that the plan document drives, not the corporate reimbursement policy.

Why are subscribers paying high premiums only to get reimbursed at Medicare rates? It makes no sense. That is why Medicare for All is not a concept that providers support. Your organization will never be able to survive on Medicare rates unless the rates are substantially enhanced. Non-profits who take Medicare rates have other sources of income: federal, state, county and foundation grants, as well as independent donations. Most of these other sources of income are not available to for-profit organizations within the substance use treatment ecosphere.

For-profit providers need to understand and advocate for rates that are based upon real costs of providing services, not some arbitrary number selected by a payer.

Increasing Payer Denials Due to Corporate Reimbursement Policies

Pre-payment review, two words that are the bane of any providers existence, the second most hated phrase post-payment review. Medical record requests, payment delays, and claim denials which negatively impact a provider’s cash flow are the key elements of either review.  Depending upon the payer, a review can last up to 18 months putting strain on a provider’s financial resources and dramatically increasing costs.

These corporate policies are trumped by the patient’s Certificate of Coverage. You should and must get a copy of the patient’s plan documents. While it is not the easiest process, it should become a standard requirement during admissions. Then, someone must read the plan document.

Once again, the plan document drives all reimbursement and if there is a conflict between the plan document and the corporate policy, the plan document always wins.

Focus Upon Evidence-Based Treatment

This topic makes me give any provider reading this tough love. Over the years, I have had thousands of conversations with providers that say that the number of days for substance use treatment are declining. I ask can you prove to me that more days are clinically advantageous based upon your program? With most providers, the answer is we are working on it.

If you cannot prove that patients within your program benefit from extended treatment days, the payer is not going to take your word for it. How are you tracking results for at least a year after treatment ends? This is particularly important for residential treatment providers and intensive outpatient treatment providers.

Payers have significant data about medication assisted treatment (MAT), and because of the coronavirus crisis, also about telehealth. That evidence-based data has put components of the substance use treatment industry at risk.

Empirical data is suggesting that payers want patients to go through a short detoxification period, then put the patient on MAT with telehealth services. Hence, the ever-decreasing days for residential and IOP treatment. Why? Our industry has no data to counter the payer’s data suggesting that a step down immediately to MAT with telehealth services is not good treatment. It is time that the substance use treatment industry provides an alternate narrative: more residential and IOP treatment days equals longer sobriety and lower relapse percentages. That is what providers tell me; the industry needs to provide proof.

Insufficient Clinical Documentation

Clinical documentation is key to reimbursement. The payer motto is “if the service is not documented, it did not happen.” Some providers do not understand this. Are the start times recorded for every group and individual session? Is there a treatment plan that is periodically updated? Are clinical laboratories reviewed and do the results affect patient treatment? Is there a prospective discharge plan?

Simple documentation requirements that unfortunately get missed and the payer uses these errors to place your organization on pre- or post-payment review. Your organization should have a process for clinical documentation review. Why? Each payer has different clinical documentation requirements. Each speaks a different language. If you are in France, you need to speak French. If you are documenting for Aetna, you need to document in the language that Aetna requires and understands. Read the medical necessity documentation and make sure your clinicians include it in their documentation for each patient. Be careful, documentation must be customized to each patient, no boilerplate.

In January, California adopted the American Society of Addiction of Addiction Medicine(ASAM) standards for substance use treatment, as have may other states. That should make clinical documentation easier by simply applying the ASAM levels of care. Providers must know what the ASAM standard says, then apply it to their clinical documentation. The result will be less denials based upon medical necessity. In California and other states, ASAM reigns. Apply the standards in all appeals or whatever payer standard applies in your state. Who reviews your clinical documentation? If the answer is no one, you will be on pre- or post-payment review before you finish this sentence.

More Lawsuits from Both Sides

I am not a fan of lawsuits and believe that providers often end up upside down after settlements. Essentially, the cost of achieving the settlement is more than the settlement itself.

Some law firms will analyze your case and take it on contingency. Contingency means if the law firm does not win the case, you pay nothing. If the law firm wins the case you can pay up to 40% of all the proceeds from the settlement.

Lawsuits also throw your issues over to the payer legal organization and magically everything slows down. Your organization is officially in a lawsuit. Expect the resolution to take multiple years.  In the meantime, expect virtually no payments from the payer you are suing.  That is why you should use the regulatory environment, your state department of insurance or the department of insurance of the state where the policy was issued, before initiating a lawsuit. At the best it will get settled much faster, at the worst your organization has gathered documentation to be used in a lawsuit. Specialized healthcare consultants can help you with managing regulatory complaints.

Lawsuits can be effective but before initiating one your organization should understand the risks. Payers will do almost anything to win or delay reimbursement. In Wit v. United Behavioral Health, the judge said:

“This case arises out of pervasive and long-standing violations of ERISA by United Behavioral Health (“UBH”). UBH denied mental health and substance use disorder treatment coverage to tens of thousands of class members using internal guidelines that were inconsistent with the terms of the class members’ health insurance plans. UBH engaged in this course of conduct deliberately, to protect its bottom line. To conceal its misconduct, UBH lied to state regulators and UBH executives with responsibility for drafting and implementing the guidelines deliberately attempted to mislead the Court at trial in this matter.”

Conclusion

The judge’s ruling in Wit v. United Behavioral Health summarizes what the substance use treatment ecosphere is up against. As one of the founders and the president of the Addiction Treatment Advocacy Coalition (ATAC), as well being a nationally recognized pre-payment review and post-payment review consultant, I fight against insurers every day. Providers can reduce the chance of being placed upon review and increase reimbursement by doing the following:

• Checking the payer website every month for reimbursement or medical necessity changes
• Requesting the plan document or Certificate of Coverage upon admission
• Understanding the reimbursement within the plan document or Certificate of Coverage
• Understanding whether the plan document conflicts with corporate reimbursement policies
• Gathering data on patient outcomes over a year period to prove evidenced-based treatment
• Complaining to regulatory authorities; early and often
• Understanding that lawsuits should be the last alternative and your organization should have the financial wherewithal to take the lawsuits to conclusion
• Joining and supporting advocacy organizations, like the Addiction Treatment Advocacy Coalition, to ensure someone is fighting for your organization every day.