This presentation should help clarify some of your questions on insurance admissions and to respond to some basic question the patients may have prior to their admission.
Why it is important to work the insurance intakes as much as the private pay intakes.
Most commercial policy have either an in-network contract or out of network contract, with some policy having both in and out of network benefits.
PPO affiliation: LAP in-network with BCBS/Magellan PPO, Value Options, Cigna/GM, Compsych. NO HMO. PPO affiliation: MH Out of network with all insurance (policy must have OON coverage)
Eligibility: Policy must be effective prior to admission or treatment.Non active coverage: Policy termed or termination of employment or non payment for month to month policy.Cobra: Payment to extend coverage after policy term. Patient either pays directly to insurance company or bring the payment at admission along with the cobra paper work.Pre-exiting: Insurance companies impose an exclusion for care base on either a particular diagnosis or length of coverage.Benefits: Detail descriptions of what exactly the policy covers. What portion of care is the patient’s responsibility and what portion is the insurance responsibility.
Mental health and substance care are base on different level of care base on medical necessity which make up the 30 days stay. Most patient will stay for 30 days in treatment at different level during that stay. The insurance companies have strict guidelines for qualification at those level of care. A full face to face assessment at the upon admission is required to determine at what level of care the patient will be placed.
These are some basic information necessary for pre-admission and admission. The pre-admission step is a crucial part of the intake assessment in order to ensure a smooth admission in our facilities.
Jd Revised Undestanding Insurance Eliigibilityprocess Iii
2009 ___ Insurance Data<br />31% of VOB’s done in 2009 converted into admissions <br />84%of the total admissions in 2009 were Insurance based<br />± 2% margin of error <br />
In Network vs. Out of Network Coverage<br />In Network – Per-Diem Rates contractually agreed upon by both parties. <br />Blue Cross Blue Shield-<br />In-network at __ only with low daily rates requiring high OOP<br />Out of network at ___ usually with a higher net revenue allowing for little OOP<br /> United Health Care-<br />Out of network at all facility usually a higher net revenue allowing for little OOP<br /> Cigna Health Care-<br />Out of network at _________<br />In-network at ________ (effective 10/7/2010)<br />Aetna-<br />In-network at ____ONLY (effective 7/1/2010) <br />Out of Network at ____<br />Value Options- <br />In-network at ____<br />Out of network at _____<br />Compsych-<br /> In-network at ___<br /> Cannot go to ____ Will not pay Out of network providers<br />Ad-Hoc Policies (GHI, MHN, Humana… etc)<br />Out of network at all facility usually a higher net revenue allowing for little OOP<br />
In Network vs. Out of Network Coverage cont…<br />Out of Network - ___ has no contract with a specific insurance carrier for an agreed upon rates<br />____ submit bills based on our “stated billed” charges or on the insurance “usual and customary” charges<br />GHI, Humana, Principle life , MHN, or any Ad-Hoc plans<br />Out of network at facilities usually have a higher OOP for the Patient, as a higher Net Rev for the facility<br />Single Case Agreements- Special negotiated price between a provider and the insurance company(Payer)<br />Eligibility and benefits may not be applicable and/or no coverage available for a specific facility or Provider type<br /> Arrangements can be made, if allowed by the insurance, for the policy to cover a one time special approval for care<br />
Plan Types:<br />Traditional PPO (Preferred Provider Organization) <br />PPOs allow the member to see any healthcare provider they want<br />The premium for a PPO is generally higher than that of an HMO with a higher deductible and OOP cost for the member<br />PPOs will pay between 70-80% of medical expenses <br />The use of OON benefits in PPO plan is often discouraged by insurance carriers<br />Traditional HMO (Health Maintenance Organization)<br />The premium for an HMO is usually very low and has a low deductible and OOP cost for the member<br />Requires members to see only doctors or hospitals within their network of providers<br />Requires that the member chose a primary care physician, who will direct care and refer patients to approved providers<br />Generally the HMO will not, cover medical expenses incurred by seeing a provider or facility not contracted with the HMO network<br />
Insurance Coverage cont…<br />EPO- (Exclusive Provider Option)<br />Type of managed care plan that combines features of HMOs and PPOs<br />With an EPO, the member must select a primary care physician or physician gatekeeper who will be responsible for meeting your health care needs<br />EPO plans are much smaller than PPOs, they have a very limited number of providers who offer large discounts on their rates<br />It is referred to as exclusive because the employer agrees not to contract with any other plan services <br />POS- (Point of Service) or Open Access<br />POS plan is a hybrid of the HMO and PPO plans. Like an HMO plan, a primary-care physician and contracted doctors and facilities is given to the member, the PCP's role is to coordinate all aspects of the patient's health <br />But unlike an HMO, you may opt out of the network. If you opt out you'll be responsible for paying a portion of the provider's bills.<br />Similar to a PPO plan, POS also gives you the flexibility to seek doctor care in and out of network and still receive most of their insurance benefits<br />With POS health insurance you have greater freedom, but at a higher cost<br />
Eligibility and Benefits<br />Eligibility<br />Active Coverage<br />Yearly renewal coverage (1/1/10 – 12/31/10)<br />Month to month coverage<br />Self Funded<br />Non-Active Coverage Types<br />Cobra<br />Exclusions to plan eligibility<br />Certain doctors<br />Levels of care; DTX, RES, REHAB, PHP and IOP<br />Facility Type<br />Required licensing and accreditation; STATE LICENSE, JACHO or CARF<br />Pre-existing: based on certain diagnosis or prior credible coverage:<br />An exclusion period imposed on the policy for a length of time. Any care must be given at the end of that period. The subscriber can choose to show proof of prior coverage to reverse the exclusion<br />Exclusion can also be based on a certain diagnosis, usually chronic and often costly medical conditions such as: diabetes, heart problems, mental illness, cancer, COPD <br />
Eligibility and Benefits cont…<br />Benefits<br />General Benefits/Coverage - Medical, Dental, Vision, Durable Medical Equipment, Pharmacy<br />Deductibles, Co-pays, OOP, Co-insurance, lifetime maximum, annual maximum applies to these benefits<br />Behavioral Health Benefits- overseen by the American Society of Addiction Medicine. (ASAM) Based on the Level of functioning (LOF), Level of Care (LOC) Chemical dependency (CD) resulting in the need for INPATIENT TREATMENT<br />Deductibles, Co-pays, OOP, Co-insurance, lifetime maximum, calendar year maximum applies to these benefits<br />
Government Funded PoliciesMedicaid and Medicare<br /><ul><li>Medicaid-was created on July 30, 1965, through Title XIX of the Social Security Act </li></ul>Medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services<br />Each state may have its own name for the program. Examples include "Medi-Cal” in California, "MassHealth” in Massachusetts, "Oregon Health Plan” in Oregon, and "TennCare”in Tennessee<br />Medicaid is available only to certain low-income individuals and families who can't afford medical care pay for some or all of their medical bills<br />Medicaid typically has a low reimbursement for services provided<br />Most doctors, facilities, do notaccept medicaid<br />Medicaid like most HMO Plans has a limit on which doctor or facility the member can obtain care<br />Medicaid not accepted<br />
Government Funded PoliciesMedicaid and Medicare cont….<br /><ul><li>Medicare-was created on July 30, 1965, through Title XIX of the Social Security Act </li></ul>Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over, or who meet other special criteria. <br />The program also funds residency training programs for the vast majority of physicians in the United States<br />Medicare program have four major parts, which operates as a single-payer health care system<br />Part A Hospital Insurance <br />Part B Medical Insurance <br />Part C Supplemental (Medicare Advantage Plans)<br />Part D Comprehensive drug coverage<br />Neither Part A ,Part B, C or D pays for all covered medical costs. The programs contain premiums, deductibles and coinsurance, which the covered individual must pay out-of-pocket<br />Medicare can also be a supplemental plan for people who are aged 65 and over who are still employed and carry a primary or secondary commercial plan<br />
Financials<br />Patient Financial Responsibility<br />IN-network and OON deductibles and Co-pays-a fixed dollar amount the patient is required to pay upfront before the policy begins to reimburse for services rendered, these dollar amounts usually renew every year<br />Co-Insurance– Usually the 10% to 40% of the cost that the policy will not cover after services has been rendered to the patient, the patient will be balance billed once payments has been received by insurance<br />Room and Board- Non-covered Servicefees NOT associated with the clinical care the patient receives while in treatment, such has lodging, food and laundry<br />Pharmacy and/or miscellaneous- Fees associated with prescription drugs that will be administered to the patient while in treatment<br />
Behavioral Health Levels of Care<br />Inpatient Residential Treatment <br />Average LOS – Most insurance plans covers 30 to 45 days for inpatient treatment base on medical necessity <br />Levels of care – Overseen by The American Society of Addiction Medicine Assessment (ASAM)<br />Detoxification (DTX)<br /> Average stay at DTX 5-7 days<br />Based on acuteness of intoxication, withdrawal potential, biomedical conditions and complications. Emotional/behavioral conditions and complications, treatment acceptance/resistance , relapse and recovery environment. Provided with a 24HR medical and skilled nursing supervision.<br />Inpatient/Residential<br />The highest intensity of medical and nursing care provided within a structured environment. Persons require a more sustained treatment program in a controlled environment for stabilization and/or differential diagnosis <br />Average stay 8-10 days<br />
Behavioral Health Levels of Care cont…<br />Inpatient Residential Treatment<br /> PHP (Partial Hospitalization Program)<br /> An intensive non-residential level of service where multidisciplinary medical and nursing services are required. <br />Average stay 8-10days<br />Can also be performed on an Outpatient setting averaging 6 to 9Hrs<br />IOP (Intensive Outpatient Program)<br /> Multidisciplinary, structured services provided at a greater frequency and intensity than routine OP. These services range from 90 minutes to 4 hours per day up to five days per week. Common treatment modalities include individual, family , group, and medication therapy. <br /> Average stay 15-25 days per program<br />Outpatient/Therapy – Less intensive level of service provided by psychiatrists, psychologist, therapist and or counselors. Typically provided in an office setting from 60 to 90 minutes (for group therapies) per day<br />
Pre-admission screening information<br />Intake assessment<br />Protected Health Information (PHI) HIPAA regulated<br />Patient name, DOB, social security, home address<br /> Subscriber's name, DOB, social security, home address and employer<br />Insurance Name and phone number<br />Insurance ID number and group number <br />Clinical Data (Phone interview or Face to Face Assessment)<br />What (Drugs/Alcohol/Other substance)<br />Mental health/Psych related issue (Bi-polar, Anxiety, Depression)<br />When (last date of use and/or current pattern of use)<br />Biomedical conditions, Psych conditions<br />How much, How often <br />Contributing family history/Psychosocial issues<br />Why now(Precipitating events)<br />Placement (Determination)<br />