What We Do
SERVICES THAT WE OFFER
Pay for Services Here
- MHAIP is here to help. For Families:
- We file appeals and grievances on behalf of individuals/families seeking mental health treatments and autism treatments on a sliding scale fee. We handle regulatory intervention and external reviews with state regulators.
- We have amassed a national team of attorneys that we hand cases off to if we are denied. Many will work on a contingency basis.
- for facilities & providers
- We will draw up and submit claims and medical records, and conduct pre and ongoing authorizations, for all your clients, for a percentage of what we bring in, or for individual clients, at their request.
- For ABA and other Providers: We provide advice, webinars, trainings, consultation, and direct appeal services to assist your families with coverage and/or help you recover unpaid claims and appeal denials.
Families – Mental Health
Final Regulations of the Federal Mental Health Parity & Addictions Equity Act explicitly state that residential treatment is a covered benefit. These regulations became active on July 1, 2014 and after, as plans renewed. These regulations impact nearly all health plans, except for grandfathered plans and a small number of ERISA exempt government plans.
MHAIP has had success in obtaining insurance coverage for medically necessary residential, partial hospital programs, and intensive outpatient treatments for adolescents and young adults with mental health conditions. The new regulations have changed the landscape for residential treatment coverage. When medically necessary, it should be covered for most health plans.
Facilities – Mental Health
If you are considering admitting your child or young adult to a Residential Treatment Center, and would like to receive coverage, follow the steps below to maximize your chances of obtaining insurance reimbursement. You may also contact us to assist you in the process as we have successfully recovered over $100,000 for individual families.
- Document the behaviors that warrant admission, and obtain documentation of these behaviors from licensed professionals, school personnel, and medical doctors. Behaviors include uncontrolled risk taking that creates an immediate risk to self or others; rapid decrease in level of functioning in several areas of life (school, family, interpersonal), to the degree that the individual is unable to care for him or herself, and/or likelihood that individual will not improve in their current environment.
- Children and youth typically should receive some level of "out-patient" care, such as weekly psychologist visits, in order to justify the need for more intensive treatments, although if there is a significant precipitating event, or if the person repeatedly refused to go to therapy, we have been able to bypass this. This type of requirement, known as “fail-first,” is thought to be a violation of the Federal Mental Health Parity Act and can be challenged with insurance carriers.
- Prior to admission, contact your health plan for a list of "in-network" residential treatment centers. If none of them are appropriate for your person, call the plan back and request a single case agreement or gap exception to a specific out-of-network facility prior to admission. Be prepared to explain why and how this facility can accommodate your child's unique needs in a way that the in-network facilities cannot. If you are working with an educational consultant, they can often help explain why a given program is appropriate and another would not be.
- While you are exploring residential options, ask potential centers if and how they work with insurance, and let them know that this is important to you. Increasingly, this is becoming a factor influencing families’ decisions. Do they have someone that calls the plan and requests initial and ongoing authorization? Do they do this in-house, do they contract it separately, or do you, the parent, contract it? We are happy to work with your facility of choice. It is easier for us to get funding if you reach out to us before you start.
- The health plan may want to speak with someone from the program. Often when we work with families, we get permission from both families and facilities to speak with insurance on their behalf. When we call to obtain pre-authorization, we often review medical files in advance, so that we can present an argument to your plan on why the services are necessary. We will call the plan and explain what has been going on that makes the services necessary. When we are successful, we will obtain the date of next review, send in claims for the covered period, and call back when the approved timeframe expires.
- If the request is denied, the insurance company is legally required to inform you of this in writing. They cannot just say that services are not covered, or that it is not medically necessary, they have to tell you WHY. We carefully review the reasons given for denial, and address that in our appeal. We also carefully review the plan manual, to see if the reason given for denial is actually explained in the plan manual. If it is not, we can argue that the plan is using a hidden exclusion, which is generally not allowed. Most health plans are no longer allowed to deny residential or other intermediate forms of therapy for coverage reasons.
Working With Mental Health Facilities
At Residential Treatment Centers & Wilderness Programs our top priority is helping the teens and young adults you work with! Wrangling with insurance companies consumes valuable time. We assist facilities in navigating the insurance maze so that you can do what you’re best at—helping youth!
We offer comprehensive insurance services including pre-authorization, ongoing utilization review, billing, and appealing denials. We manage all contact with the insurance companies on behalf of your facility, unless the health plan specifically wants to discuss clinical information with a “peer” (known as “peer-to peer” reviews). Then we advise the treating clinician on how to best engage with the reviewer and what to highlight.
When treatments are denied, we are seasoned experts at handling first and second level appeals, external reviews, and involving state regulatory bodies when insurance companies are not abiding by the law. We are also connected to attorneys in numerous states who work on contingency and will take cases the final round if needed. We prefer to obtain coverage for patients on the front-end, but we have also been highly successful in recovering over $100,000 for individual families.
Working With Wilderness Programs (aka "Outdoor" Behavior Programs)
We have worked successfully with several wilderness programs advising them on how to obtain coverage for their families, doing some of the pre and ongoing authorizations, sending in invoices and medical records after the fact, training staff on insurance billing, and handling appeals.
Many plans will dispute Wilderness therapy and say that it is harmful, experimental or unproven. But we have taken the time to educate regulators, attorneys, and others in the field and share the wealth of evidence based literature amassed on the subject. The OBH Council has summarized some of the recent changes and advances in the field with respect to insurance coverage for wilderness here.
Some states have a separate license for outdoor behavioral health, while other states license both standard RTC and Wilderness with one residential license. Some wilderness programs have participants live in a traditional facility several days a week, and go out on expeditions every few days. Others build competency with nature through gardening and agriculture, and clients live in a regular facility. We have had success working with many types of wilderness programs. Frequently plans will change their reason for denial after our initial appeal, subsequently allowing review for the clinical facts. Sometimes plans will deny for coverage, but we’ll point out that there is no exclusion in the manual. Some state regulators will not allow plans to deny for wilderness, interpreting it to be a violation of parity
Thanks to the hard work of generous attorneys who brought multiple class actions for wilderness denials, many families are now starting to get settlement offers for wilderness therapies.
Why Deal With Insurance At All?
Prior to the passage of both the Affordable Care Act (ACA) and the final regulations of the Federal Mental Health Parity and Addiction Act (MHPAEA), few families had the expectation that insurance would cover much if any of their child’s residential, partial hospital, or intensive outpatient treatments. But changes in the ACA now require that health insurance companies build adequate networks, INCLUDING residential treatment facilities (RTC), partial hospital programs (PHP), and intensive outpatient programs (IOP)(all are “intermediate forms” of therapy). Many families are now investigating how they can get their health insurance to at least partially cover their child’s treatment.
Facilities that continue to avoid the task of working with insurance will increasingly be left out of consideration when families choose a placement. Families with generous PPO plans will expect that RTCs to meet them at least halfway, which includes obtaining or contracting out pre and ongoing authorizations, providing case notes and medical records, and supplying insurance ready invoices. We know this sounds like a lot of work. That's why we are here.
Effective Record Keeping & Incident Reports
Incident reports and effective record keeping are critical to continued insurance coverage. When we begin working with a facility, our first step is to clearly explain how to improve record keeping in such a way that will satisfy insurance requirements.
Consultation And Trainings
We provide trainings, in person or via phone or skype, to help your staff work with insurance. We offer trainings on pre-authorizations, ongoing utilization reviews, coding, billing, following up on obtaining payments and appeals.
How Do We Charge?
Some of our services are available on a contingency basis, depending on how much money we recover. We do not charge for an initial consultation, or to review the initial facts of an individual case. For other services, we charge hourly rates, and offer discounts to non-profits. We also offer services to families on a sliding scale hourly rate.
To discuss working with us, please contact us.
Families – Autism
SERVICES THAT WE OFFER
Appeals And Requests For Independent External Review
We assist families with loved ones with autistic spectrum disorders obtain medically necessary treatments through insurance. We work to help families obtain coverage behavioral health treatment, as well as speech therapy, occupational therapy and physical therapy. We handle health plan denials (both for coverage and medical necessity), and regulatory intervention. We do the initial appeals, and we write requests for independent external review with state regulators, as well. We work in MANY states, and have a high success rate. We also appeal denials from self-funded ERISA plans. Sometimes we will refer to attorneys after the internal appeals phase is exhausted.
Single Case Agreements
Often health plans do not have an adequate network of providers that can work with the growing ASD population. When we encounter situations like this, we encourage families to thoroughly investigate their network. If nobody with the appropriate expertise is available, we encourage them to call back the plan and request a single case agreement with a non-network provider, if they know of one. If they don’t know of one, we encourage them to reach out to local special needs parent organizations, as we have found that other parents are often the best resource. MHAIP will often step in and file grievances, appeals, and complaints with the regulators when plans lack an adequate network and are unresponsive to requests to assist.
Problems With Billing
If there were problems with billing or coding, we can review documents, determine the problem, and with permission from providers, re-do and resubmit bills.
Speaking Engagements
We offer speaking engagements and trainings to community organizations, parent support groups and others that want to learn more about accessing insurance.
Providers – Autism
We understand that as providers, your top priority is helping the children you work with! Wrangling with insurance companies consumes valuable time and we are here to help. We assist healthcare providers in navigating the insurance maze so that you can do what you’re best at—helping children!
What Services and Treatments Can Be Covered?
Intensive behavior therapy, speech therapy, group social skill language therapy, occupational therapy, and physical therapy are all medically necessary treatments, and are covered benefits under many state autism mandates. With the passage of the Affordable Care Act, fully-funded plans in all states must now offer habilitative care in parity with rehabilitative care. They also cannot discriminate against consumers because they have a known disability -- they should no longer be denying care because it is a treatment for a developmental disability. Furthermore, because autism is characterized by insurance as a mental health condition, restricting the number of sessions for things like speech and occupational therapies for autism treatments likely violate Federal MHPAEA. Most health insurers know this, and often will approve these treatments when you call them on it. More and more self-funded plans are also offering these medically necessary treatments, many voluntarily, and some due to litigation (or threat thereof).
Recovery Of Money For Services Owed
Even when you do everything by the book and have authorizations in writing, it is sometimes challenging to get paid for services owed. Providers sometimes get in touch when they are owed in the hundred thousands. We are adept at reading through EOB statements, verifying non-payment, and getting plans to pay, with interest. For fully insured plans, we are happy to bring in the regulator, as well, and they are often happy to help. We are very efficient at recovering money, we charge on an hourly basis, not a percentage, which is usually much more reasonable than using a collections agency.
Effective Report & Assessment Writing That Results In Funding From Insurers
While many health insurers are required by law to provide ABA therapy, speech & OT, insurers are only required to provide these treatments when they are considered "medically necessary." Insurers may argue treatment is not medically necessary for a given patient. They may argue that the patient does not have severe enough symptoms to warrant treatment. Or they may argue that the patient is so severe that they are not likely to show improvement from the treatment. They may argue that the treatment should be obtained through the school district. Therapists need to be aware of these common arguments, and how to address them in writing up assessments, and progress reports. When care gets denied, sometimes it is a matter of rewriting the report to highlight what the health plan felt was lacking. We will work directly with providers and advise on how to write up reports to maximize the likelihood of getting covered.
Resolve Medical Necessity Related Disputes
As an autism service provider who accepts insurance, you should be seeking pre-approval from insurers before providing services for intensive behavioral treatments or ABA. We see cases where services are denied initially, and also upon renewal. When plans deny for medical necessity, they are required to tell you why. The most common reasons we see are slow progress, or has made sufficient progress and no longer needs treatment. Each argument needs to be appealed on its own individual merits. MHAIP assists families and providers through the appeal and regulatory review processes.
Employers & Employees In Self-funded Plans
Self-funded plans are paid for by employers. As such, they are not held to the same stringent requirements as fully-funded, state-regulated plans. You cannot tell that a plan is self-insured by looking at the card. Providers need to verify to make sure that autism benefits are covered, and at what amount, before services begin. It is important to know what is and is not covered when working with self-insured plans. We can help and advise you on this. Sometimes when you are having trouble getting funding from a self-funded plan, it helps to speak up and let the employer know that the plan that they are paying to administer health services is not providing the help and service that they should be providing. We have had success by reaching out to employers.