If you are thinking about enrolling your troubled teen in a residential treatment program, price has more than likely been a point of discussion. These facilities often come with a hefty price tag. Perhaps you’ve been close to going forward with a program you felt was right, but never committed because it was unaffordable.
The information in this article will describe in some detail how to go about leveraging insurance to take care of some, most, or all of the costs associated with teen residential treatment centers. Armed with the right knowledge, it’s possible to beat the insurance companies by playing their own game.
If you can make yourself less ignorant and more attentive than the average policy holder, you can soon find yourself more than able to afford enrolling your child in a residential treatment program. The following information is applicable to most therapeutic programs such as intensive outpatient programs, therapeutic boarding schools, wilderness programs, and others.
How do insurance companies interact with residential treatment centers?
In other words, what kind of relationship do residential treatment programs have with insurance companies?
Though the definition of RTCs sometimes differs from one insurance provider to another, the criteria is typically the same. To an insurance company, RTCs are categorized as providing substance, behavioral health, and specialized mental health treatment in an overnight facility where food, shelter, safety, and clinical services are provided.
Though each state has their own licensure procedures, these treatment facilities are also placed into three “care” categories- intermediate, subacute, and residential. Residential, which is primarily being discussed here, implies 24 hour care.
What criteria are insurance companies looking for?
There are a handful of particular points that most insurance companies will be looking for when asked to subsidize a residential treatment program bill.
Make sure that you have checked most or all of these boxes before communicating with your insurance provider:
- You and your troubled teen have tried weekly outpatient therapy sessions with little to no success, justifying a higher and more specialized form of treatment.
- You obtained a directory of in-network options from your health plan before requesting their help to pay for program enrollment.
- Proof that your teen’s behavior has created an unsafe home environment.
- Proof that your teen’s ability for self-care has been severely diminished due to their behavior.
- Your child’s current environment (home, school, etc) has become detrimental to their growth.There is good reason to believe that residential care will have a better chance of success.
Requesting insurance intervention
It’s recommended that you start by writing a letter to your provider recommending that your teen be admitted to a treatment center.
Be sure to include copies of tests and assessments that have been completed by medical professionals as well as official recommendations for admittance. Your letter should make clear that outpatient therapy up to this point has not worked and should be descriptive with why your teen isn’t progressing in their current environment.
Document at-risk behaviors that require 24 hour care. Illustrate to the insurance company that a residential treatment program will have a better chance at helping your troubled teen due to their clinical interventions and evidence-based therapies.
After you’ve composed and sent the letter, contact the residential treatment program and request that they contact the insurance provider for pre-authorization. This is the terminology used by insurance companies to mean that permission to engage in a higher level of care has been given. Be sure to get a document or a number that confirms admission approval.
After these steps have been taken, call your insurance company every day asking for updates. It shouldn’t take more than 5-7 days but history has shown that the more persistent you are, the better your chances are of getting financial help.
What to do once the insurance company has accepted your request
During the admissions process with the residential treatment program, be sure to ask about or look for the following things:
- The facility is licensed and credentialed in its respective state.
- A discharge plan exists that has been explain to you.
- Family therapy will be provided on a weekly basis.
- Weekly meetings about medication have been scheduled with a doctor.
- Your teen will receive individual therapy once a week (at least).
- A biopsychosocial intake (multidisciplinary assessment) is scheduled to be performed within days after admission.
- Your teen will have 24 hour access to medical care and will have access to onsite nursing.
- A physical and urine screening will be performed.
What to do if the insurance company denies your request
Don’t give up. Make an appeal and try not to get upset. Many people eventually receive help from their insurance providers even after they’ve been denied.
Make sure that you request a written denial if only a verbal one was initially given. You want to save this for your records because it will detail the particular reasons why your request was denied – what criteria you did not meet.
This is important to know because, depending on the state, insurance providers are required to pay for any treatment that is considered medically necessary by a doctor. This usually includes conditions categorized as severe mental and/or physical illnesses.
In many cases, just because an insurance provider says they won’t pay doesn’t mean that they aren’t required to. Sounds strange, but that’s the nature of the insurance game. They don’t want to pay, but when pursued with persistence, they are often required to.
In the event that you submit an appeal and are denied again (or are ignored by the insurance company), you can contact the regulatory body in your state that deals with insurance compliance and request what’s called an independent review.
Remember, we recommended that you be persistent. Keep pressing. When attorney’s and regulators are involved, it’s surprising how many denials are reversed. In conjunction with an independent review, be sure that you send a letter that details the dispute.
Include a cover letter and use certified mail. Include everything – and we mean everything – that you sent to or received from your insurance company during the entire process.
Don’t forget your doctor’s letter, the one that recommends a residential treatment program for your teen. And don’t rule out getting an attorney involved. The fee very well may be worth it.
Does this process apply to therapeutic boarding schools?
Yes.
Make sure that during the communication process with your insurance provider, you make it clear that you want your teen referred not as a student but as a patient. Requesting a physical assessment for your child is helpful in maintaining the “patient, not student” mindset.
You’ll want to emphasize not the academic nature of the program but more-so the therapeutic nature. If you reassure your insurance provider that you will send them records – service notes, medical notes, treatment plan updates – on a regular basis, this will increase the chances of them helping with the bills.
It seems that insurance companies love as much documentation as possible, so be sure to give it to them – everything from the admissions process to the exit strategy and everything in between. Get them as much documentation as possible as early as you can.
What to do if the insurance provider is uncooperative
Contact insurance regulators in the state where treatment is to be provided.
Are retroactive insurance payments an option?
Yes, but it’s much harder to get financial help from an insurance provider after treatment has already been administered.
It can be done, but the process is arduous and even more time-consuming than the one we’ve explained in this article. In your letter, you’ll need to be very clear and sufficiently convincing in your explanation as to why you didn’t understand or were never informed that treatment could be covered.
Can PHPs be covered?
Sometimes.
PHPs (Partial Hospitalization Programs) provide care that focuses on troubled teens with substance, behavioral, or mental health issues that don’t necessarily call for 24 hour care. These situations would be described as hospitalization or inpatient scenarios rather than residential center enrollment.
Many residential treatment centers provide day treatments and temporary hospitalization that offer medical monitoring, education, discharge planning, structured activities, therapeutic groups, and other helpful services.
Though these programs are great, insurance doesn’t always cover it. They sometimes do, but that will depend on your particular provider and your particular circumstance.
One thing to consider here is that some patients participating in residential treatment programs have the option of stepping down into a PHP if the center they’re currently enrolled in offers them. If you’re considering this at any point for your troubled teen, communicate with your insurance provider to see if this is covered.
If a provider does cover PHPs, it is almost always at a daily rate, sometimes referred to as a per diem rate. Most providers won’t cover overnight stays when dealing with PHPs.
It’s a good idea to educate yourself on how your teen’s particular treatment center bills for PHPs before you go forward with one.