Tip #1: Understand Who the Biggest Insurance Payers Are in California for Addiction Treatment and Get Comfortable Working with Them All
The California health insurance market is robust with competition, which makes sense for a $222 billion dollar industry. Yes, you read that right.
When you examine the market share of each payer, you’ll see that Kaiser Permanente is by far the largest insurer in California with a 31% market share, followed Blue Shield at 10% market share, Anthem and Centene (aka HealthNet) at 9% market share, UnitedHealth at 7% market share and LA Care at 4% market share. The remaining carriers capture a full 30% of the market.
In other words, at your addiction treatment center, it’s likely you’re dealing with a lot of different payers. This is not the case in some states, where there are really only a few players in the game. The billing departments in the Golden State have to work overtime to keep up with the myriad different requirements and tricks involved in successfully completing claims for such a diverse roster of providers.
Tip #2: Make Sure to Master Addiction Treatment Billing for Blue Shield California
It’s likely that most of your patients will carry Blue Shield in California.
Although Kaiser has a larger market share of the overall health insurance landscape, they are notorious for under-treating behavioral health and mental health concerns. Kaiser is most likely to handle addiction treatment in a primary care setting, perhaps offering digital tools or outpatient treatment for those who don’t find relief at their PCP’s office. Getting pre-authorized for inpatient treatment with Kaiser is rare.
Billing Blue Shield for addiction treatment in California is a complex, but doable process.
Like Kaiser Permanente, Blue Shield is increasingly pushing patients into virtual behavioral healthcare and “robo-treatment” with virtual treatment portals and recovery education apps. These tools can be easily deployed at scale to push down costs for payers or “manage liabilities.”
Knowing that getting reimbursed for traditional addiction treatment in an inpatient, residential, or IOP setting is an uphill battle is the first step. Knowing how to win that battle is the second step.
Mastering utilization reviews at Blue Shield of California will help give your addiction treatment center the edge it needs to ensure that your patients get the care they deserve.
Tip #3: In California, You Can Request Utilization Review Criteria for Addiction Treatment at Any Point
Thanks to the California Mental Health Parity Act of 2020, also referred to as SB855, addiction treatment providers can ask payers about utilization review criteria at any point in the billing process. Generally speaking, payers usually only make this information available while denying a claim or during the appeal process after a claim has already been denied. With the Parity Act, payers must inform you of the rules of the game ahead of time — and then abide by those rules, at least in theory. This shift in transparency is of huge value to addiction treatment billing departments. Where trial and error was once the order of the day, billing departments are now able to “pick the brain” of the claims department and become more sophisticated in how they write their claims.
Tip #4 Empower Your California Addiction Treatment Billing Department With a Strong Working Knowledge of the Accepted Standard of Care
Thanks also to the Parity Act of 2020, payers are beholden to the “accepted standard of care” for addiction treatment services. For example, it is no longer legal in California for payers to authorize only seven days of inpatient treatment when the standard of care mandates at least thirty days. Your addiction treatment billing department can leverage a working knowledge of the standards of care to advocate for patients around everything from prior authorization of care, to a higher level of care and/or a more therapeutic length of stay.
That’s why it’s so important that your billing department has a working knowledge of the addiction treatment standards of care. These standards of care are sometimes also referred to as “established clinical guidelines.” For addiction treatment, the ASAM criteria is perhaps the most important one to pay attention to. Some other key clinical guidelines to familiarize yourself with are:
Level of Care Utilization System guidelines (LOCUS)
Child and Adolescent Level of Care Utilization System guidelines (CALOCUS)
Early Childhood Service Intensity Instrument guidelines (ECSII)
World Professional Association for Transgender Health guidelines (WPATH)
Tip #5: Consider Opening a Sober Living Home to Support the Mission of Your Addiction Treatment Center
Sober living is a big business in California and can help with cash flow issues related to billing headaches at an addiction treatment center. We’ve written elsewhere about how to open a sober living home in California and some new funding opportunities for sober living home operators in the Golden State, as well.
Need More Help With Addiction Treatment Insurance Billing in California? We’re Here for You.
Dealing with insurance billing in-house is usually an expensive time waster for busy addiction treatment centers and providers.
BehaveHealth’s Revenue Cycle Management (RCM) service includes soup-to-nuts, hyper-detailed, hands-on attention to every single component of your addiction treatment billing needs. We have strong working relationships with every major insurance company in the United States.
Even better, we’re not health care generalists. We only work for behavioral health providers like you.
Let our team of specialists handle it all:
Verification of Benefits
Utilization Review
Billing and Collections
Patient Responsibility
Denials and Appeals
Get your free trial started today and see why more addiction treatment centers prefer Behave Health.