Chances Are, Your Patient is Covered

Thirty-five years ago, when Cyndi Eddington, retired Vice President of Revenue Cycle Management at ERC Pathlight, accepted her first job in mental health, she knew she had found the right field. “I loved what I was doing,” she says.

Decades later, she saw firsthand how important having access to mental health care can be. Not long after she joined ERC Pathlight in 2012, Eddington learned that her daughter, then 18, needed care for an eating disorder. A few years later, her youngest son needed care for an anxiety condition.

“I was fortunate to understand insurance and obtain benefits that let me access incredible professionals who could support my kids,” she says. “But I realize not many people who require mental health coverage for themselves or a loved one have that level of knowledge.”

Eddington built what she calls a “Financial Treatment Team” at ERC Pathlight. Its goal: to bridge the gaps between providers, payers and patients. “The team is passionate about sharing what we’ve learned about navigating insurance for mental health care,” Eddington says. “We feel like it’s our pay-it-forward moment.”

Coverage Expands

A profound shift in mental health coverage occurred in 2008 with the passing of the Mental Health Parity and Addiction Equity Act. It required mental health coverage to be no more restrictive than insurance coverage for other medical conditions.

The initial act applied only to group health plans. But the passing of the Affordable Care Act in 2010 extended mental health parity to individual health insurance coverage too.1

However, virtual therapy at higher levels of care, which utilize a milieu or group therapy model, was not yet covered. “While mental health parity created widespread coverage for intensive outpatient programs (IOP), virtual IOP was considered an alternative method of care and was excluded,” Eddington explains.

That changed during the COVID-19 pandemic, when virtual health care became widespread and the federal government, state Medicaid programs and private insurers expanded coverage for telehealth.2 “Payers learned during the pandemic that IOP could be provided effectively through telehealth services,” Eddington says. “Now, with few exceptions, Eating Recovery and Pathlight At Home, our virtual IOP, is covered by all major carriers.”

One of the most significant benefits of coverage for virtual IOP is the way it expands access to mental health services to people in rural areas. “I grew up in a small town in Minnesota. It was at least a 500-mile drive into Minneapolis to get specialty services, like treatment for an eating disorder,” Eddington says. “Now, with the increase in virtual IOP coverage, people can get the very best care for eating disorders and other mental health conditions no matter where they live.”

Virtual IOP as Preventive Care

Sometimes providers hesitate to refer to virtual IOP because they believe a payer won’t authorize a patient for the treatment until that patient’s health condition reaches a more advanced stage.

From a clinical standpoint, however, the best time to refer a patient to Eating Recovery and Pathlight At Home is as soon as it’s clear that the patient is not making progress in outpatient care and requires additional support. “The sooner we can deliver care to someone during their illness, the higher the probability they will have a sustained recovery,” Eddington says.

She recommends that providers rely on ERC Pathlight to help them overcome insurance questions or barriers to referrals. “If open questions are causing you to defer potential early intervention into a higher level of care, lean on us,” she says. “We understand if a patient will meet the standard of medical necessity and we’ll help you and your patient through the authorization process.”

Advocates for Patients and Providers

Providers who choose to refer a patient to Eating Recovery and Pathlight At Home will get guidance at every step. Most often, providers will initially talk with an admissions coordinator who will manage the pre-authorization process, which includes scheduling an assessment with an ERC Pathlight master’s-level clinician. The assessment results will determine the recommended level of care for the patient and will give payers the information they require to complete insurance payment authorization.

During and after treatment, the Financial Treatment Team will help ensure accurate adjudication of covered services on behalf of the patient.

Knowing that patients who need virtual IOP already face multiple stressors, Financial Treatment Team members see themselves as patient advocates. “We understand that our assistance makes an incredible difference in the lives of families and patients because they’re in a difficult place right now, unable to take in a lot of the complexity,” Eddington says. “When someone is advocating for you to get the best financial outcome, it makes an impact.”

Learn more about Eating Recovery At Home and Pathlight At Home, our virtual intensive outpatient programs for eating disorders and mood and anxiety disorders. Available and accessible across the nation, these programs are covered in-network by most commercial insurance plans.

Citations:

1. U.S. Centers for Medicare & Medicaid Services. (2022). The Mental Health Parity and Addiction Equity Act (MHPAEA)
2. Health Resources and Services Administration. (2022). Billing for telehealth during COVID-19. U.S. Department of Health and Human Services