If you’re running an addiction treatment center, IOP program or any type of behavioral health concern in Pennsylvania, you’re no stranger to red tape. The state has some of the most extensive licensing requirements we’ve encountered here at Behave Health.
It should come as no surprise, then, that the insurance side of the business is also relatively complicated.
Today, we’ll look at everything you need to know about undertaking insurance billing for addiction treatment in Pennsylvania.
Who Are The Biggest Addiction Treatment Health Insurance Providers in Pennsylvania?
Pennsylvania has 1,552,396 people insured with large group market plans. The largest group market insurer is Highmark Group, with 39% market share. Next is Independence Blue Cross Group, with 20% market share. FInally, We have Capital Blue Cross Group with 11% market share. There are many other insurance companies active in Pennsylvania, but those are the biggest three.
Does Pennsylvania Have Parity Laws That Affect Addiction Treatment Insurance Coverage Above and Beyond the Standard Federal Regulations?
The answer to this question is YES. According to the Pennsylvania Insurance Department:
In Pennsylvania, we have mental health parity which means that your health insurance company is required by law to provide you with the same level of health insurance coverage for mental health and substance abuse disorder treatment as you would have for medical/surgical services.
The reality is, however, that these laws, like their federal counterparts, are rarely if ever enforced. That leaves many insurance companies actively working to avoid playing behavioral health claims due to the nature of the disease being treated.
What is Act 106 and How Does it Affect Addiction Treatment Billing in Pennsylvania?
Measure 106 requires all addiction treatment insurance companies operating in the state to cover basic addiction treatment at every level of care. Typically, this means:
7 days of detox (with a lifetime cap of 4 episodes)
At Least 30 days residential treatment (with a lifetime cap of 3 episodes)
At least 30 IOP sessions (with a lifetime cap of 120 sessions)
Family counseling and intervention
30 additional IOP or PHP sessions or 15 additional residential treatment days (patient’s choice)
These straightforward laws allow for easier planning and programming at addiction treatment centers.
Pennsylvania Has “No Surprises Act” Law Regarding Behavioral Health and Other Categories of Care
Pennsylvania has legislation that makes provisions for effectively eliminating surprise medical bills that result from out-of-network office visits and procedures. More specifically, if a patient ends up at an out-of-network provider’s office through no fault or even intention of his own, then they may not be charged a “balance bill'' to cover the difference between in and out of network care. These laws don’t apply when another network provider is available, but they do apply when a treatment center or treatment contractor’s beds are all full. Providers are also required to supply patients with a detailed breakdown of cost estimates.
Many Pennsylvanians Fall Prey to Addiction Treatment Centers That Engage in Insurance Billing Fraud - But Not Usually In Pennsylvania
7,157 Pennsylvanians accessed addiction treatment in the past two years. Of those, 17% sought out-of-state facilities, namely centers in Arizona, California and Florida. These states are notorious for unethically managed addiction treatment centers. Because the problem is so pervasive, even in Pennsylvania, the state government has started issuing warnings to Pennsylvanians to question the trustworthiness of out-of-state recruiters and promises of cheap, discounted or free treatment in sunny locations.
Other Posts from our Blog That May Interest Those in Addiction Treatment in Pennsylvania
What Addiction Treatment CPT Codes Require Pre-Certification at Highmark, Inc.?
How to Open an Addiction Treatment Center in Pennsylvania
4 Quick Tips for Managing Addiction Treatment Discharges with Independence Blue Cross
Want More Help With Addiction Treatment Billing in Pennsylvania?
Behave Health is committed to making it easier - and more profitable - to operate evidence-based, results-focused addiction treatment centers.
Our all-in-one app puts clinical, administration, staff, admissions, alumni, residents, treatment plans, billing, insurance authorizations and more - all at your fingertips.
Get your free trial started today and see why more addiction treatment centers prefer Behave Health.
Need help with certification? Behave Health can also help direct you to the right resources for help with Licensing or Accreditation by either The Joint Commission or CARF. Mention to your product specialist that you’re interested in this service after you start your free trial!