Clinicians in private practice have a lot of autonomy. But none of us “go it alone” - we work with a network of other providers, support services, community resources and institutions. When a client has an urgent need for additional help, we are often the “front line” in making that connection - in fact, we may be the only professionals that distressed person talks to. Of course we want to get them to the best care possible, but too often clinicians end up trying to navigate the same maze clients and families get trapped in, between shady marketers and obdurate insurers, trying to assess facilities without direct interaction. Sometimes it seems like the whole process is in the way. Getting clients the care they need means negotiating with insurers, employers and sometimes the client themselves. Winning the insurance battle can be frustrating, time consuming - and essential to effective client care. Often it feels like we need a “secret handshake” to get through the door. What follows are some of our best tricks of the trade for getting it done.
When a client needs a referral for inpatient care, detox, or addiction rehabilitation services, it’s a moment of crisis and opportunity: usually there is an urgent need and a narrow window in which the client is willing to accept the help he or she needs so badly. In order to optimize outcomes from these crisis moments, preparation is essential.
When a clinician reaches out to a facility, there are questions you should be prepared to answer: Is this an emergency? Is the client also the policy subscriber, or a dependent/spouse? The insurer and the facility may want to speak directly with the client and/or the subscriber. Making sure everyone is on-board and available for that conversation may be critical.
Most importantly, we want to make sure that
● the facility is a clinical match to client needs
● client’s insurance is compatible
● deductibles and copays are affordable.
Beware: if a facility offers to cover or waive deductibles or copays, this is a red flag to other unethical or even illegal behavior! Of course clients want to save money, but ensuring that their treatment is safe, effective, above-board and ethical is our job as clinicians.
Every Policy is Different
Any admission that happens outside an emergency room is a challenge in some of the same ways. Of course every client has different insurance, and even within a group plan or for dependents from a primary earner’s plan, benefits can vary. If you are able to get a copy of the insurance policy - not just the card - when you start working with a patient, it can make a lot of these processes in the moment much easier. It may be daunting to ask, either at the outset of the relationship or when you begin to suspect that a client may need additional help, but it can save a lot of headaches later.
Within a policy, coverage for independent practitioners or small practices is generally considered “clinical coverage,” but the rehab services we might refer out to are often classed as “facility services,” which are billed under different coverage codes. Learning which facilities are and are not covered, and under what codes may be surprising and inconsistent. Check and re-check the particular policy against the specific program within a facility to be sure. Most of the time treatment centers will do their own benefits verification. Knowing your client’s mental health and SUD benefits ahead of time can be the secret handshake that protects your relationship with your client from benefits exhaustion when they go to treatment. Ideally, when treatment is billed as a “facility service” it can leave the “clinical services” plan limits untouched.
Some insurers will write a check to the client, rather than to the treatment provider; this is a particularly problematic practice with addiction treatment, and it will benefit all involved if you know in advance the insurer’s practices so you can help make arrangements to ensure that money gets where it needs to go.
Medicare is different from any other kind of insurance, including other government-administered coverage. Medicare only pays for day treatment and detox. If a patient needs inpatient treatment, that can only be provided by a hospital, and only a few hospitals provide that care. Clinicians need to know local hospitals that provide Medicare treatment; older clients with addiction issues will depend on what information you have on file - or saved as “favorites” on your GetHelp App - , because they probably won’t be able to find those resources on their own.
Medicaid varies by state, and often within states will contract through private providers who have their own rules. Again, their facility coverage is very different from their practitioner coverage, and it will be useful to know your local providers’ practices.
Having access to reliable, unbiased information about the financial options and insurances accepted at treatment centers in your area, and the facilities that can work with Medicare, Medicaid and uninsured patients, can be the secret handshake to give your client treatment options.
Out-of-Network May Not Mean Out of Reach
Most clinicians have facilities they prefer. If you have preferred facilities, get their admission criteria and the insurance plans they work with. Have information readily available for a few local places as well - it’s not too difficult to find a few facilities that match the provider mix of your practice. You may want to speak to the insurance companies directly, but most of them have this information on their websites.
Once a clinician establishes a relationship with a facility, the in- and out-of-network boundaries sometimes soften. For a client who is particularly well-matched to a particular treatment center, the facility may be able to create a “single case agreement” with the insurance company based on particular criteria. It doesn’t always succeed, and it’s a lot of extra work for the facility. Their willingness to invest time and energy in the process may depend on their relationship with you as an ongoing referent. This ongoing relationship may be a secret handshake that gets your client through the door.
Interventionists Do More Than Plan A Conversation
“Intervention” means everything is in place before the individual agrees to go to treatment. This takes time and energy on behalf of the clinician, the client’s loved ones, the facility and insurer. This is one of many reasons why working with an interventionist can be practical as well as efficient. Working through these details may be best left to a specialist. Interventionists know more secret handshakes than you do. For a complicated client, the advocacy of an interventionist may be essential. Even in more straightforward situations, interventionists can save you valuable time while optimizing outcomes.
When your client is going to treatment, you may have choices as to how involved you will be with their acute and ongoing care. “Referent status” is the secret handshake that permits access to a client and their records, and allows you to be involved in decisions regarding their ongoing treatment plan. Whether you want to ensure that a client returns to your practice, or that they are safely in more appropriate hands, referent status allows you to speak frankly with the facility about plans going forward. There is a benefits component to this conversation, however - and understanding the client’s insurance allows you to have a more thorough and productive conversation with the facility about benefits consumption and care planning.
Get Help Is the Secret Handshake App
Having information you can trust about reliable, ethical treatment centers within your clients’ reach can seem like its own job - because it is. And at Get Help, we’re doing that job for you. The Get Help ecosystem is an ethics-forward, client centered network of treatment providers, clinicians and interventionists you can count on when you need them. Simple filtering tools allow you to find the treatment centers that can work with your clients’ insurance; within that subset finding the people and institutions whose focus and modality is most suitable for a particular client is simple and fast. And Get Help allows you to speak directly to those facilities - no middleman, no brokering, no follow-up sales calls from shady marketers.
Get Help is the secret handshake. We take the mystery - and the time-consuming research - out of the process. Your clients Get Help. You get your time back, so you can give help the way you know best. We believe that any addict seeking recovery should be able to find the help they need quickly, ethically, and simply. We believe that clinicians and facilities can work together to create optimal outcomes for clients in need. We believe facilities can best define, describe and explain their treatment options without being mediated by a commission-driven middleman. Our simple app costs nothing to use, and changes the process - saving you time and energy before, during and after you seek additional help for your client.
Download the Get Help app, check out our website, or be in touch with us directly to find out more about how we work, what we do, and our vision for transforming addiction treatment by changing what happens on the front lines - when a client or clinician first reaches out to Get Help. Our free search tool is the easiest way for anyone, anywhere to find addiction treatment fast. You can download our app on iTunes, go to www.GetHelp.com, or call us at (323) GET-HELP. We look forward to working with you.