Many people have a love/hate relationship with their health insurance. This feels even more painful for those struggling with 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 improved yet, we still have a distance to go where mental health is supported with the robust care it deserves.
The Insurance Challenge Facing Ketamine Providers
Many doctors are hesitant to take on a relationship with health plans due to the experience with delays in payment, declining payment and the tremendous overhead required to file claims. Providing psychedelic assisted therapy is a very labor and resource intensive service. Yet, this is necessary level of service as we recognize that providing a high level of service and avoiding skimping on care results in improved outcomes. People get better with the deep support we have committed to provide. Currently, insurance companies have not been able to understand the benefit of high levels of support and interface with patients.
We have worked with 3rd party financing companies to support our patients in assisting with fair credit options. Fair is important to us. We don’t want to create another issue in our patients lives with potential unfair credit practices.
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, compassionate and dedicated business with the uncertainty of 3rd party reimbursement from health plans. 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. We are very hopeful…stay tuned.
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. We continue to be very focused on how we can make this work for our clients.
How We Plan to Expand Insurance Coverage for Ketamine Treatment
ShaMynds Healing center is currently not contracted with payors. We provide superbills or documentation that can be submitted as out of network benefits. Sometimes the health plans will pay for the services as an out of network benefit.
Our hope is to increase communication with these plans 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. Another interesting development is that as MDMA is moving forward with its approvals in the treatment of mental health, it seems that health plan payors are structuring a payment that just might work. When Can I Get MDMA Therapy? · Psychedelic Support
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 or Health Plan
As part of your decision to move forward with ketamine assisted therapy, find out what your health plan might potentially cover. Here are some questions:
- What are my out of network benefits for mental health?
- What is my current out of network deductible at this time?
- What type of paperwork can I submit to get coverage for out of network mental health services?
- What is the process of reimbursement for the costs I pay from my pocket?
You can also escalate your questions to someone in finance or benefits who can better understand the nuances of your health plan and the questions you are asking. It could be a costly decision.
Working Together to Advocate for Insurance Coverage
As we move into 2022 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 certainly deserve the very best of care available at the best price option available.
