Using health insurance and Medicare for alcohol, drug rehab and substance abuse treatment at First Step Services, LLC
Posted on May 23, 2014 by Henry Tarkington
- Using health insurance:
1. During the phone call for the initial appointment, have your health insurance information available.
2. Bring your Health Insurance card to the initial appointment. Information on the card must be accurate and up to date. Expired cards are denied by insurance. We do not need your actual Medicare card; only the Medicare Advantage card.
3. Arrive to the initial appointment 15 minutes early to complete the insurance coverage financial document or “CMS1500” red and white form.
4. Know the name, address, date of birth, and insurance card of the insured if the card is in the name of a parent, spouse, or other.
5. First Step will verify benefits and obtain pre authorization as needed.
6. All insurance companies we are in network with authorize attendance at our 3-hour groups. Some plans cover 1-1/2 to 2-hour groups.
7. Insurance companies typically preauthorize 7 – 12, 3-hour group sessions that must be attended within a certain number of days.
8. To qualify for coverage, 3-hour groups are initially scheduled 3 times per week. The frequency of attendance is reduced as determined by number of sessions necessary and progress in group counseling.
9. After the initial 7 – 12 preauthorized sessions are completed, a re-authorization is required. During re-authorization, insurance companies request information regarding progress, abstinence, drug tests, community support, family involvement, etc.
10. If a request for authorization or re-authorization is denied, clients can often overturn the denial by phoning the insurance company and appealing for coverage.
- First Step Services, LLC role:
1. Accurate documentation of information on the insurance card and CMS1500 form.
2. Obtaining pre-authorization and re-authorization to ensure coverage of services.
3. Answering questions required by insurance companies and requested by clients.
4. Billing all claims and handling insurance company requests for information and records.
5. Following up, resubmitting and filing appeals on denials.
6. Providing accurate, up to date invoices and financial statements to clients/patients.
– Are you in network with health insurance?
– Will my insurance cover this appointment?
– What do I need to provide for you to be able to bill my insurance?
– Do I have to send invoices to my insurance company?
– Do you take Medicare? Yes, we are in network with most insurance companies and related Medicare Advantage Plans.
First Step is in network with all the major health insurance companies to ensure your services are covered. We do the billing for you. You don’t typically have to send anything to your insurance company. Schedule an assessment and tell the person on the phone that you plan to use insurance and provide information about your insurance plan. When you come in for your first appointment bring your insurance card. We are required to have a copy of it on file to authorize and bill insurance. We cannot accept insurance until we have a copy of both sides of the unfolded card.
When possible, arrive a few minutes early for your initial appointment. Upon your arrival you will complete the “CMS1500 form.” This insurance form provides the necessary information required for authorizations and billing. If the insurance is in the name of a spouse, parent or any other person, the insured’s full name, date of birth, employer’s name, etc. are required on the form.
– Am I responsible for contacting my insurance company?
The initial appointment typically doesn’t require preauthorization. If you are unsure, call your insurance company for information. Some insurance plans pay for initial assessments but some do not. Most plans that pay for assessments only pay for it if you actually start the program and there is billing for counseling or treatment. The assessment is part of treatment. Some companies don’t pay unless billing for treatment is begun. Substance use is considrered a healthcare concern. Insurance companies often expect their customers to begin receiving services within or 3 – 5 days after the assessment. Otherwise, they could view it as “not medically necessary.”
– How does the insurance process work?
Substance use causing job or school suspension, drug/alcohol charges or DWI is a healthcare concern. Receiving an assessment and waiting to see what will happen with court, school or at work before entering treatment could cause denial of coverage.
Once the assessment is complete and a level of care has been recommended, we call the insurance company and get “preauthorization” to provide the services. This is standard for substance abuse & mental health coverage. There is usually no problem getting authorization. Typically re-authorization is required by insurance every few sessions. First Step handles billing. We will help answer all questions if you let us know what you need.
For re-authorization, insurance companies require information regarding how well patients/clients are participating in counseling are they remaining completely abstinent during the course of treatment, is the family involved, are they attending a recovery program (such as 12-step), are they attending as scheduled, etc. To ensure continued coverage, insurance expects full participation in the program. Health insurance pays for substance abuse counseling because it is a health-care need or “medical necessity.” You do not have to be an alcoholic or a drug addict to be covered; even a mild-moderate use disorder is a healthcare concern.
Insurance companies ask if about the motivation level of the insured client. Most of our program participants want to at least stop getting into trouble for alcohol or drug use.
– My insurance is through my employer; will my employer find out that I come here if I use my insurance?
No. Insurance companies can not inform your employer, or anyone else for that matter, about your treatment. All health records, especially substance use treatment, are protected by Federal law and cannot be shared. Federal regulations 42CFR, Part 2 covers substance abuse treatment confidentiality requirements. There are few exceptions. If one is suicidal, homicidal or there is evidence of child abuse or endangerment appropriate notifications are made under strict guidelines. Your confidentiality is of utmost importance and mandated by federal law.
– What does co-insurance mean and why do I have to pay that?
Concerning cost, typically the only fee a patient must pay is a co-pay, and the deductible. Most co-pay is around $25 per session. If you have a deductible, we do everything we can to help alleviate costs. We allow people to come to treatment and pay an adjusted rate until the deductible is met. Depending on the reimbursement rate, it usually results in no added cost to the patient.
– I have a high deductible how will using insurance help me?
If you wonder if it is worth using insurance because you have a high deductible, it is usually best to use it. It helps pay down your deductible so that if you need insurance for something in the same fiscal year, your deductible will be largely, if not completely, met. For more information on how we work this out, call the First Step nearest you. Our goal is to help you get through treatment and not break your bank.
Will my insurance company use this treatment against me in the future or raise my rates?
Using your health insurance to cover your treatment should not increase your rates. The Federal Government enacted a “mental health parity law” a few years ago, requiring insurance companies to treat substance use treatment in the same manner it handles any other doctor’s visit or service. We don’t know of increases happening as a result of treatment. Patients & former patients tend to keep us informed of most things like it.
– What happens if my insurance stops covering my treatment?
By being in network, we help our patients & clients not have to risk the pitfalls of using an out of network provider. If you lose your insurance or are no longer authorized after some sessions, we reduce your cost to our typical “hardship rate” which is much lower than the insurance contracted rates. If you lose your job and are no longer able to pay anything, we will discuss options with you. It is rare that we can’t come to an agreement on a plan that works both for you and First Step.