Cornesha Broadway | American Addiction Centers

Rehab Admissions Process

<h2>What is Prior Authorization?</h2>
Prior authorization, sometimes called pre-authorization or prior approval, in healthcare, refers to the requirement that your provider (physician, hospital, etc.) obtain approval from your health insurance plan before performing a healthcare service, carrying out a treatment plan, prescribing a certain drug, or giving you a medical device. Without prior authorization, a health plan or insurer may not cover the costs of the service, program, drug, or equipment, leaving you stuck footing the entire bill—instead of your portion.2
<h2>How Does Prior Authorization Work?</h2>
Prior authorization can be done either electronically or manually. For prescription medications, prior authorization runs through electronic prior authorization (ePA) technology, which works to automate the process as follows:3
<ol>
 	<li>The healthcare provider selects the medication in the e-prescribing system.</li>
 	<li>Prior authorization is indicated if necessary and prompts the system to begin the process.</li>
 	<li>The ePA gets submitted before the healthcare provider submits the prescription to the pharmacy.</li>
 	<li>After the ePA is submitted, the health plan responds in real time with questions specific to the medication and the patient’s pharmacy benefit.</li>
 	<li>The healthcare provider (or staff member) submits the answers to the health plan.</li>
 	<li>A decision may be received with minutes.</li>
</ol>
The prior authorization for services, treatments, and devices isn’t as quick and simple as the ePA technology. To receive prior authorization for a healthcare service, you will need to follow some simple steps.
<ol>
 	<li>Contact your provider. Call your healthcare provider and ask what they need from you to begin the prior authorization process.</li>
 	<li>Fill out the paperwork. Forms generally include personal information as well as information about your medical condition and needs. It’s important to fill these forms out thoroughly and accurately.</li>
 	<li>Keep a paper trail. If your prior authorization is denied, you may need to refer to the paperwork, so don’t get rid of anything. It’s also handy to have a record of approved prior authorizations should you need the treatment, service, or device again.</li>
</ol>
Prior authorizations are intended to keep healthcare costs in check. By requiring a prior authorization, your health insurer or plan wants to ensure that the service or medication is necessary to treat your condition and that it’s the most economical solution.

Not surprising, this process meets with controversy since prior authorizations can lead to treatment delays and prevent patients from getting the care they need when they need it. Additionally, for individuals with ongoing conditions, needing repeated prior authorizations can hinder their progress.4
<h3>How Long Does It Take to Get Prior Authorization?</h3>
The length of time to get prior authorization varies by state, method of prior authorization transmission, and the urgency of the service or medication.5 In most cases, prior authorization requests for medications, using ePA, get responses within 2 business days but typically within 24 hours. On the other hand, manual transmissions for healthcare services may take up to 15 business days to get a response. In urgent situations, decisions typically come within 72 hours of submission.5
<h2>How to Get Prior Authorization for Rehab</h2>
Rehab falls under the umbrella of behavioral health services and is deemed essential. Therefore, health <a href="https://americanaddictioncenters.org/insurance-coverage" target="_blank" rel="noopener">insurance covers at least a portion of rehab</a>.  While all plans must cover behavioral health treatment—like psychotherapy and counseling—mental and behavioral health inpatient services, and substance use disorder treatment, the specifics vary by individual plan.6 

Historically, health plans required prior authorization for substance use disorder treatment, but the delay in treatment initiation places individuals at risk of continued substance use, overdose, and death. As a result—and in response to the opioid epidemic—state lawmakers removed some of the prior authorization requirements for addiction treatment.7 Check with your plan to see if prior authorization is required for addiction treatment.

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<h3>What Happens If Prior Authorization is Denied?</h3>
In some cases, prior authorization is denied. You have the right to appeal your plan’s denial. First, find out why the prior authorization was denied. Some common reasons for denial may include:8
<ul>
 	<li>The service, treatment, medication, or device was not deemed medically necessary.</li>
 	<li>The particular benefit is not covered under your plan.</li>
 	<li>The prior authorization for services comes from an out-of-network provider.</li>
</ul>
If your prior authorization is denied, you have the right to appeal the decision in 1 of 2 ways:9
<ol>
 	<li>You can request an external review by an independent third party, which eliminates the insurance company from having a final say.</li>
 	<li>You can ask the insurance company to perform a full and fair review of its decision. If your service or medication is urgent, they must do this in a quick and timely manner.</li>
</ol>
<h2>Finding an Addiction Treatment Program</h2>
If you or a loved one struggle with addiction, American Addiction Centers (AAC) is here to answer your questions, <a href="https://americanaddictioncenters.org/verify-insurance" target="_blank" rel="noopener">verify your insurance</a> benefits, and explain your treatment options. We can also help you find out if your plan requires prior authorization and how to go about getting that if they do. Don’t let that stop you from getting the help you need. Call [phone]

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[link-bank title="You Might Also Be Interested In"]
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 	<li><a href="https://americanaddictioncenters.org/rehab-guide/medicare" target="_blank" rel="noopener">Medicare for Rehab</a></li>
 	<li><a href="https://americanaddictioncenters.org/rehab-guide/free" target="_blank" rel="noopener">Free Rehab Programs</a></li>
 	<li><a href="https://americanaddictioncenters.org/rehab-guide/rehab-faqs" target="_blank" rel="noopener">FAQs About Rehab</a></li>
 	<li><a href="https://americanaddictioncenters.org/payment-options" target="_blank" rel="noopener">Rehab Payment Options</a></li>
 	<li><a href="https://americanaddictioncenters.org/blog/how-to-pay-for-rehab-without-insurance" target="_blank" rel="noopener">Paying for Rehab Without Insurance</a></li>
</ul>
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[sources]
<ol>
 	<li>American Medical Association. (2022, July 12). <a href="https://www.ama-assn.org/practice-management/prior-authorization/what-prior-authorization" target="_blank" rel="noopener">What is prior authorization</a>?</li>
 	<li>Healthcare.gov. (n.d.). <a href="https://www.healthcare.gov/glossary/preauthorization/" target="_blank" rel="noopener">Preauthorization.</a></li>
 	<li>American Medical Association. (n.d.). <a href="https://www.ama-assn.org/practice-management/sustainability/prior-authorization-practice-resources" target="_blank" rel="noopener">Prior authorization practice resources.</a></li>
 	<li>Association of Health Care Journalists. (2018, August 9). <a href="https://healthjournalism.org/blog/2018/08/prior-authorization-rules-yet-another-way-the-health-insurance-system-frustrates-physicians-and-patients/" target="_blank" rel="noopener" data-component="link" data-source="inlineLink" data-type="externalLink" data-ordinal="1">Prior Authorization Rules: Yet Another Way the Health Insurance System Frustrates Physicians and Patients</a>.</li>
 	<li>American Medical Association (AMA). (n.d.). <a href="https://www.ama-assn.org/system/files/2021-04/pa-state-chart.pdf" target="_blank" rel="noopener">2021 prior authorization state law chart.</a></li>
 	<li>Partnership to End Addiction. (2020, May). <a href="https://drugfree.org/reports/spotlight-on-prior-authorization/" target="_blank" rel="noopener">Spotlight on Legislation Limiting the Use of Prior Authorization for Substance Use Disorder Services and Medications</a>.</li>
 	<li>Healthcare.gov. (n.d.). <a href="https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/" target="_blank" rel="noopener">Mental health &amp; substance abuse coverage.</a></li>
 	<li>Community Health Advocates. (n.d.). <a href="https://communityhealthadvocates.org/healthcareqa/fight-a-denial/" target="_blank" rel="noopener">CHA can help fight a denial.</a></li>
 	<li>Healthcare.gov. (n.d.). <a href="https://www.healthcare.gov/appeal-insurance-company-decision/" target="_blank" rel="noopener">How to appeal an insurance company decision.</a></li>
</ol>
[/sources]

Insurance Prior Authorization for Addiction Treatment

Especially when it comes to drug and <a href="/alcoholism-treatment">alcohol treatmen</a>t, navigating the ins and outs of healthcare insurance can seem daunting. When people start talking about in-network versus out-of-network providers, <a href="https://americanaddictioncenters.org/insurance-coverage/ppo">PPOs</a>, <a href="https://americanaddictioncenters.org/insurance-coverage/hmo">HMOs</a>, and out-of-pocket maximums, it’s easy to tune it all out and put off treatment for another day.

In reality, though, healthcare isn’t all that complex—and treatment is vital. A few minutes of reading is all you need to gain a basic understanding of in-network and out-of-network treatment options. And even if a rehab facility is out of network, it doesn’t mean it’s necessarily out of reach financially.

Read on to learn more about out-of-network rehab insurance, coverage, benefits, and more—and to discover how to get in touch with a host of professionals that can walk you through the insurance maze and the entire admissions process.
<h2>What Does it Mean if a Facility or Provider is Out-of-network?</h2>
Insurance companies typically create a network of healthcare providers, facilities, and physicians that then provide care to their members. Providers within each network, aka <a href="https://americanaddictioncenters.org/rehab-guide/in-network" target="_blank" rel="noopener">in-network providers</a>, have contracts with the insurance companies in which they agree to offer specific (typically lower) prices and services for insurance plan members. For example, a healthcare provider may normally charge $200 for a service, but as an in-network provider for ABC Insurance, it might charge ABC patients only $90 for the same service.1

If a provider is out-of-network with a specific insurance company, it means it isn’t part of that company’s network, which is to say it’s not contracted to provide special services or pricing. As such, it can charge patients a much higher rate in some cases.1

So how does it affect your coverage or pricing if you choose an out-of-network rehab provider?

Simply put, it depends, as in-network versus out-of-network coverage varies. For example, your plan may offer some coverage for out-of-network care, but it'll probably be less than what it provides for in-network care.  For instance, your plan may pay 80% of your costs with an in-network provider but only 60% with an out-of-network provider. Here’s a breakdown of some of the more common insurance provider types and their out-of-network coverage.1
<ul>
 	<li>Preferred Provider Organization (PPO) plans often offer out-of-network coverage. And while you typically don’t need a referral to use out-of-network providers, you’ll likely pay a larger percentage of the costs than you would with an in-network provider.</li>
 	<li>Point-of-Service plans (POS) plans are similar to PPOs, but you’ll likely need a referral from a primary care provider in order to see a specialist.</li>
 	<li>Other insurance plans, such as Exclusive Provider Organization (EPO) and Health Maintenance Organization (HMO) plans, don’t pay any benefits for care (except for emergency services) from out-of-network providers.</li>
</ul>
Note, however, that as of Jan. 1, 2022, the <a href="https://www.cms.gov/nosurprises" target="_blank" rel="noopener">No Surprises Act</a> provides some protection against surprise bills from out-of-network facilities and doctors. These regulations also mean providers have to supply you with clear information about costs and options, which can make it easier to evaluate out-of-network care and truly understand the financial implications.2
<h2>Why Do People Sometimes Choose Out-of-network Providers?</h2>
Despite the potential coverage limitations of out-of-network providers, some people may still choose to use them for a host of reasons, including:
<ul>
 	<li>Patients may need emergency care—or medical assistance while traveling—in locales where there are no in-network providers available. </li>
 	<li>Patients may prefer to see a trusted practitioner that’s out of network due to their long-standing history and high degree of trust with the provider.</li>
 	<li>An out-of-network specialist or specialty facility may offer the best treatment to fit the needs and wants of the patient.</li>
 	<li>Patients may have selected an in-network provider (e.g., a hospital), but that provider uses out-of-network services, such as anesthesia or lab services.</li>
 	<li>Some people may believe they get a higher level of care when their providers are not contractually obligated to offer lower rates via in-network contracts.</li>
 	<li>When it comes to out-of-network benefits for rehab, patients may opt for an out-of-network provider simply because the treatment center offers the services (or perhaps the location or amenities) that best meet their needs.</li>
</ul>
<h2>Can I Go to an Out-of-network Rehab Facility or Treatment Program?</h2>
The simple answer is yes. Health insurance often covers rehab for <a href="https://americanaddictioncenters.org/rehab-guide/substance-use-disorder" target="_blank" rel="noopener">substance use disorders</a> and various forms of mental health treatment. And no matter what type of insurance you have, you can always seek treatment at <a href="https://americanaddictioncenters.org/rehab-guide/inpatient" target="_blank" rel="noopener">in-patient</a> and out-patient facilities that are out-of-network. But depending on your <a href="https://americanaddictioncenters.org/insurance-coverage" target="_blank" rel="noopener">insurance</a>, treatment may cost you more, or it may not be covered by insurance at all. That said, if the care that's most suitable to your needs is out-of-network, potentially improved health and happiness may be well worth the possible added cost.

Here are a few things to consider before you opt for an out-of-network treatment provider.
<ul>
 	<li>Out-of-network coverage. Before you get too deep into your exploration, first determine if your insurance offers any coverage for out-of-network providers.</li>
 	<li>Percentage Breakdowns. If your insurance allows for use of out-of-network providers, determine what percentage of treatment fees you’ll pay for in-network versus out-of-network care. For example, you may end up paying 20% of treatment costs for an in-network provider but 50% of fees for an out-of-network facility.</li>
 	<li>Referrals. Does your insurance require a referral (perhaps from your primary healthcare provider) before it will pay for treatment at an out-of-network provider?</li>
 	<li>Billing Practices. Some insurance companies bill out-of-network claims differently than in-network claims. For example, you may be billed directly for services and then have to submit a claim to recoup the costs. In this is case, it’s more of a logistical hoop to jump through than a financial one, but it’s important to understand the process from the start.</li>
 	<li>Out-of-Pocket Maximums. Your out-of-pocket maximum is the greatest amount of money you’ll pay each year in deductibles, copays, coinsurance, etc. Once you reach this figure, your insurance typically pays 100% of covered costs for the remainder of that year. Some insurance companies may not count fees for out-of-network providers toward these out-of-pocket maximums. Or, they may have a second, higher, out-of-pocket maximum for these out-of-network providers. Bottom line: It’s important to investigate your coverage thoroughly.</li>
</ul>
Opting for an out-of-network provider might sound like an insurmountable challenge. But at <a href="https://americanaddictioncenters.org/admissions/navigator-team" target="_blank" rel="noopener">American Addiction Centers</a>, we have [tooltip text="Admissions navigators are real people, some of whom are in recovery themselves, who are eager to talk with you 24/7 and to help you or your loved one find treatment. They listen to and truly hear your story. Then they help guide you through the admissions process, including exploring insurance options and payment plans, and answering any questions you have about treatment."]admissions navigators[/tooltip] who can help you investigate your insurance coverage and options. Our helpline at [phone] is available 24/7 to assist you in finding the treatment you need.

But even if you don’t have insurance, treatment centers may be able to assist you in securing grants and scholarships, or they may even use an income-based sliding fee scale to cover the <a href="https://americanaddictioncenters.org/rehab-guide/rehab-cost" target="_blank" rel="noopener">cost of treatment</a>. Once again, our admissions navigators can walk through your financing options with you. Give us a call today and take your first steps toward recovery.

[sources]
<ol>
 	<li>Health Insurance Market Place. (n.d.). <a href="https://marketplace.cms.gov/outreach-and-education/what-you-should-know-provider-networks.pdf" target="_blank" rel="noopener">What you should know about provider networks.</a></li>
 	<li>Centers for Medicare &amp; Medicaid Services. (2022, November 15). <a href="https://www.cms.gov/nosurprises/consumers/new-protections-for-you">New protections for you.</a></li>
</ol>
[/sources]

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What if My Rehab Center is Out of Network?

Cornesha Broadway received dual Master’s degrees from both Louisiana Tech University in Health Informatics, and Tulane University in Information Systems Management.  In her tenure working in different healthcare systems, she directly witnessed the effects that substance abuse had on both victims and their families.  She would often have direct contact with these patients and hear [&hellip;]

American Addiction Centers

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