Additional Authorization Requirements for Substance Abuse Facilities
You're probably used to insurers determining medical necessity and approving treatment after you've faxed clinical records. The insurer might then deny coverage after investigating further, but patient's have often started care at this point. Lately, we're seeing something different. Insurance companies have begun to increase their requirements and are investigating prior to giving authorization rather than waiting to deny treatment on the back end.
New Authorization Requirements
Recently, we needed to obtain authorizations from both Premera and Wellpoint. We anticipated both insurers requiring a clinical be faxed in order to secure authorizations, as they normally do. However, both insurers responded with different requirements than they have previously.
When intake documents were presented to Premera they responded with a relatively standard three day detoxification plan. Shortly after, Premera sent another document noting their requirements for sub-acute detox (the level-of-care we were requesting). They were requiring an Addictionologist MD to see the patient daily nursing notes created by an RN throughout the day. Typically, a sub-acute detox at a free standing facility does not require daily MD visits, and neither the MD visit nor the daily RN notes are state requirements in California.
How This Could Impact Your Facility
We've found that insurance companies are doing this more and more often. The biggest difference is that in doing so, they are many times making a determination prior to authorizing days. For example, Premera took 48 hours to make the adverse determination, and we lost two billable days. We will appeal the decision, but if your center lacks the staff to write appeals then it will almost always be a losing battle.
This type of payor-specific regulation is popping up more and more in the substance abuse and mental health field. Similarly, United Behavioral Health started requiring IMS certification to treat their members-- a requirement not regulated by the state or federal government. While these tactics used by insurance companies to deny coverage are not “fair”, it is likely that we will see much more of it in the future.
As insurers increase requirements for treatment facilities and begin investigating prior to giving authorization, it is more important than ever to have a strong and dependable treatment team. Unfortunately, for small centers it will be very difficult to get authorization without increasing your staff.
There is a small silver lining, though. Facilities will know up front that their program does not meet the requirements of a particular policy, and is less likely to receive an unexpected claim denial on the back-end.
As a best practice, you should call the insurance company at least 48 hours prior to a patient's last authorized day if that patient requires days beyond what has already been approved.