A Guide To Insurance Coverage for Ketamine Infusion Treatments (for chronic pain patients)
Advice from a Billing Expert on how this all works
The treatment of debilitating chronic and neuropathic pain conditions utilizing intravenous (IV) ketamine is a therapy that is still in its infancy. As more people turn to this breakthrough treatment for substantive relief, the focus needs to shift to the ongoing medical research as well as spotlighting best practices among those clinics providing the highest quality care in the industry.
The clinics at KWC celebrate excellent success rates in the treatment of pain conditions such as:
- Complex Regional Pain Syndrome (CRPS, formerly known as RSD)
- Other pain conditions described as Neuropathic in nature
Since we opened our doors in 2011, insurance coverage has been a focal point for speculation, debate, and questions. We are excited to have evolved our process in regards to insurance coverage for pain conditions from offering a superbill to the patient to actively assisting in the process of determining whether you are eligible for insurance coverage and placing you in the best possible position to get your treatments covered (in full or partially).
That’s where I come into the fold. My name is Karrie and I’m the Billing Coordinator here at Ketamine Wellness Centers. I speak to pain patients and insurance providers every day. I have over 20 years of experience as a billing expert and am excited to bring that into this young and exciting world of treatment. I’m also thrilled to say that KWC has gone through the credentialing process in every state that we operate a clinic in.
While KWC cannot guarantee coverage or payment of any charges or treatment costs by the patient’s insurance, I can certainly provide a prospective patient with a clearer view of whether they may qualify to have your ketamine infusion treatments covered by your insurer.
To help out with determining eligibility and setting expectations, I’ve put together what I believe to the most important points of consideration for insurance coverage for pain conditions treatable by ketamine infusion therapy.
Make sure you meet the criteria
Right now, the possibility of insurance coverage is only applicable to patients with a valid medical pain diagnosis (supporting documentation required). Furthermore, the individual must be enrolled with a commercial/private insurance provider. This only includes insurance provided through one’s employer, insurance individually purchased on the commercial market.
State or federally funded (Medicare, Medicaid, TriCare, CHAMPVA) do not qualify.
Determination is not instant
Coverage can only be determined at the time that the claim is actually processed by the insurance company. What this means is that we accept insurance on a “case-by-case” basis and that coverage is highly dependent upon individual policy coverage, the medical condition, in and out of network benefits, deductibles, etc.
Currently, only pain conditions are eligible
While we do celebrate excellent success rates treating mental health conditions such as depression, suicidal ideation, and post-traumatic stress disorder, using iv ketamine to treat mental health conditions is considered “off label” and thus, not FDA approved. We can provide a superbill for our mental health patients but ultimately, we are currently unable to bill insurance directly for that protocol of treatment.
Documentation is essential
Having that valid medical pain diagnosis in hand is the key to making this all work. This can be a copy of a medical record or a screenshot from My Chart or another online medical portal. This document must include your name, your treating physician’s name, and your pain diagnosis.
We all know how thorny insurance is. Know that you are in good hands and that KWC will advocate on your behalf. We all hope that this therapy will be covered in more transparent and broad ways, to include a larger portion of the population who could benefit from ketamine.
Please call us at 855-KET-WELL for more information or fill out this quick form and we will be in touch with you
Karrie is the Billing Coordinator for Ketamine Wellness Centers
Further Reading: Getting Insurance To Pay For Your Ketamine Treatments