The Biggest Insurance Billing Mistakes Addiction Treatment Providers Make in Ohio
Mistake #1: Not Knowing the Top Insurance Plans for Addiction Treatment in Ohio
The number of insurers offering private individual insurance in Ohio is on the decline. According to a study by the Governmental Accountability Office, there were 43 companies offering such plans in Ohio in 2011, there were only 19 remaining in 2018. As insurance payers have consolidated, there are fewer entities to contend with in addiction treatment billing departments. The top three insurers in Ohio comprised 70.5% of the individual insurance marketplace in 2018.
In Ohio, the biggest individual insurer is Cleveland-based Medical Mutual of Ohio, which commanded 35.6% of the market in 2018.
“Federally facilitated individual market exchanges” - or Obamacare plans - are administered by 8 different companies in Ohio, which actually represents a larger diversity of insurance outfits in this category than most states. 40% of this market is controlled by Caresource Management Group. A full 89% of the Obamacare market is controlled by 3 companies.
The “small group” and “large group” marketplaces are controlled by Wellpoint Incorporated Group. This company has captured over 83% of Ohio’s “small group” market share and over 82% of the “large group” market share.
Overall, addiction treatment companies and organizations in Ohio are most likely to run across plans issued by Medical Mutual of Ohio, Anthem Blue Cross and Blue Shield in Ohio, Aetna Inc, United HealthCare of Ohio, Caresource Management Group, Molina Healthcare Inc, Buckeye Community Health Plan and Paramount Advantage.
Mistake #2: Not Understanding the Parity Laws in Place in Ohio That Addiction Treatment Centers and Insurance Providers Must Abide By
Ohio, like many states, has parity laws in place to prevent insurance payers from discriminating against people with substance use disorder diagnoses or any other mental health or behavioral health condition. While federal laws exist to protect all SUD patients under disability laws, the fact is that insurance companies still attempt to shirk their responsibility to equitably provide care for these patients based on their diagnosis. Because this practice is so commonplace, many states - including Ohio - have passed what is known as “parity laws” to add an additional layer of protection for SUD patients seeking insurance coverage for their condition.
You can read more about parity laws in Ohio at the Ohio Mental Health and Addiction Services website. These can be valuable tools when advocating for addiction treatment patients who are struggling to get the insurance coverage they need.
Mistake #3: Not Knowing the Most Common CPT Codes Ohio Addiction Treatment Centers Use When Billing Insurance
Far and away, the three most used CPT codes for addiction treatment in Ohio are H0001HF, H0004HF and 96164HF.
For state-funded agencies, the most popular CPT codes are H0001HV, H0004HV and 96164HV. The difference is in the modifier. The HF modifier specifies substance use programs, while the HV modifier specifies services taking place in a state-funded addiction treatment agency. For most private facilities, the HF modifier applies.
For those programs dealing specifically with minors under 18, a third modifier, HA, is frequently used to describe services: H0001HA, H0004HA and 96164HA.
Other Blog Posts of Interest to Addiction Treatment Center Operators in Ohio
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Useful Blog Posts About General Addiction Treatment Insurance Billing
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Dive Into the Top 3 CPT Codes for Addiction Treatment: H0001HF, H0004HF, and 96164HF
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