What’s New: Insurance Options for Ketamine Therapy and How This Can Benefit You or a Loved One
For most people, health insurance is the equivalent of a four-letter word, especially if you have mental health issues or chronic pain. Since the passing of the Mental Health Parity and Addiction Equity Act in 2008 and the elimination of the pre-existing exclusion clause in the Affordable Care Act, mental health coverage has somewhat improved, but still has a long, long way to go.
The Insurance Challenge Facing Ketamine Providers
Declining reimbursements from 3rd party payers or just excessive delays in payment cause many providers to limit which payers they will work with or only accept cash payments. As we have grown our provider footprint, there are a number of 3rd party financing companies that want to partner with us to provide funding to our patients for care, however, when they find out that our patient population is primarily people dealing with depression, anxiety, PTSD and chronic pain, they quickly retreat. Sometimes if they are contracted with us, they will discontinue their services to our patients with little to no notice. One of those companies, Care Credit, gave us a one week notice of discontinuation of services and we were unable to appeal their decision. Care Credit will provide financing for veterinary medicine and non-medically required plastic surgery, but not your mental health.
My goal is not to paint a picture of gloom and doom but just to inform you why many providers and business owners just can’t be successful with the cost of running a quality business with the uncertainty of 3rd party reimbursement. However, with the recent approval of the ketamine isomer ES-Ketamine (Spravato), insurance companies are becoming more willing to cover portions of insurance claims for generic ketamine infusions for chronic pain and possibly mental health services.
Glimmers of Hope
A large number of our 3rd party payers still believe the use of ketamine for chronic pain is experimental when treating conditions like complex regional pain syndrome (CRPS), trigeminal neuralgia, fibromyalgia, and certain types of headaches. However, with the proper billing process including complete evaluation and management documentation, system reviews, and the need for ongoing medical monitoring, reimbursements can provide the needed revenue to allow clinics to be able to afford these types of payments. Many times the payer may not pay certain codes including ketamine, however, the cost of generic ketamine is very reasonable and should not be a deal-breaker.
Medicare and Medicaid cover the majority of chronic pain patients who may fall under the disabilities act for medical coverage. Medicare traditionally covers 80% of the agreed-upon amount which then leaves 20% for either secondary insurance or for the patient’s responsibility. On average, Medicare pays anywhere from 70-80% of traditional commercial insurance plans again leaving providers with the determination if they can operationally afford to deliver quality care at the reimbursable price.
How We Plan to Expand Insurance Coverage for Ketamine Treatment
Ketamine Wellness Centers is currently contracted with a number of 3rd party payers. Our hope is to increase communication with these partners to determine if they will consider paying for the “procedures” of ketamine infusion therapy for our patients struggling with mental health disorders where ketamine has proven to be effective. If we can determine that with the proper documentation, the insurance companies will hopefully accept infusion therapy for depression and mental health afflictions.
Many of our patients who have out-of-network benefits have been able to successfully submit for partial, if not complete, reimbursement for their treatments. It’s not easy at times and requires navigating the insurance albatross, however, if you pay for that service you deserve to use your coverage when you can.
Talk to your Insurance Carrier
Here are some suggested questions to ask of any provider you are considering working with:
- Are you in-network (your health plan)?
- Are your providers in the clinic in-network with my health plan?
- What is my deductible or out of pocket owed at the time of treatment?
- Do you update my deductible amount or out of pocket throughout the year?
- Do you balance bills for treatments?
I would also ask to speak with the company’s financial office, managed care, or billing director to ensure you are getting the service experts’ information and not someone who may not understand all the nuances of insurance care. It could be a costly decision.
Working Together to Advocate for Insurance Coverage
As we move into 2021 and make insurance plan decisions for our family and our own needs, it’s important to know what options are out there. Alternative treatments like ketamine therapy are becoming more popular for one reason, they work! If you are considering ketamine therapy for you or your family, do your research on the ketamine clinic, investigate your insurance options, and ask questions. You deserve the best care available at the best price option available.
If you have questions please call us at 855-KET-WELL (855-538-9355).
Kevin Nicholson BSN, MBA