Unlocking Spravato's Insurance Coverage: A Guide To Navigating Billing Procedures

Spravato is a sought-after treatment for patients with treatment-resistant depression. However, its high cost and strict regulations make it inaccessible to many. For those with insurance, understanding the billing process is crucial to minimising stress and financial concerns.

The first step is to determine insurance coverage. This includes finding out about prior authorisation, whether the healthcare provider is in-network or out-of-network, and how Medicare and Medicaid cover Spravato. Next, request a Verification of Benefits (VOB) document from the insurance company, outlining deductibles, copayments and extent of coverage. Understanding these terms is essential, as is exploring financial assistance options, such as patient assistance programs and non-profit organisations. Maintaining clear records and communicating with healthcare providers about billing concerns will help to focus on the mental health journey rather than financial worries.

Prior authorization: insurance plans may require prior authorization before covering Spravato treatment

Prior authorization is a requirement from your health insurance company that your doctor obtains approval from your plan before it will cover the costs of a specific medicine, medical device, or procedure. Many insurance plans require prior authorization before covering Spravato treatment.

Prior authorization is an approval of coverage from your insurance company, not your doctor. It's a restriction put in place to determine whether or not they will pay for certain medicines. It doesn't affect cash payment for prescriptions. Plus, it's only required for prescriptions when billed through insurance. So, if you're uninsured or if you decide to pay in cash, you won't need to worry about getting prior authorization.

The prior authorization process usually takes about 2 days. Once approved, the prior authorization lasts for a defined timeframe. You may be able to speed up a prior authorization by filing an urgent request.

Prior authorization is typically required if you need a complex treatment or prescription. Coverage will not happen without it. That's why beginning the prior authorization process early is important. Ask your health care provider if a prescription or medical treatment is going to require prior authorization so they can start the process immediately.

In the context of Spravato, prior authorization is a critical step in ensuring that the treatment is covered by insurance. It involves obtaining approval from the insurance company before initiating the treatment. This process can vary depending on the insurance provider and specific plan. It is important to understand the requirements and guidelines of your insurance plan to successfully obtain prior authorization for Spravato treatment.

To obtain prior authorization for Spravato, you should first check with your insurance provider to understand their specific requirements and processes. You may need to provide information such as the insured's identifying information, details about the referring provider and servicing providers, the requested service or procedure, the facility where the procedure will be performed, and the related diagnosis.

It is important to work closely with your doctor or the designated staff member in their office to ensure they have all the necessary information for the prior authorization request. They will need key dates for submitting the requests, so be sure to share that information as well. Having a good relationship with the representative handling prior authorizations may help create a smoother process for getting your request approved.

Your doctor may also be able to provide success stories of patients who have had similar requests, which can guide the development of your request. They may also have an existing pre-authorization process and know the typical steps, which can be helpful in understanding the next steps and the likelihood of success.

It is important to ensure that the prior authorization form is completed accurately and in full, as incomplete or inaccurate forms are common reasons for denial. Additionally, when speaking to insurance representatives, it is helpful to take notes, including the date, time, representative name, and outcome of the call. This information can be valuable if you need to follow up or have additional questions.

Once the prior authorization request is submitted, the insurance company will review it and may approve or deny it. If approved, you will be able to receive the requested treatment, but it is important to abide by any rules or terms included in the approval letter. If the request is denied, you should plan to appeal the decision. Your doctor may be able to help you navigate the appeals process and find alternative options to access Spravato treatment.

In-network vs out-of-network: in-network providers often result in lower out-of-pocket costs

When it comes to health insurance, understanding the difference between in-network and out-of-network providers is crucial to avoid unexpected bills and higher out-of-pocket expenses.

In-network providers refer to a group of doctors and healthcare providers who have a direct contract with your health insurance carrier. These providers have agreed to accept discounted rates for covered services, which helps control healthcare costs and ensures lower out-of-pocket expenses for insured individuals. By staying in-network, you can avoid unexpected bills and save on healthcare expenses.

On the other hand, out-of-network providers do not have a contract with your health insurance carrier. Without this contract, these providers are not bound to specific fees for their services, which can result in higher charges. Out-of-network providers may request payment for fees higher than what your insurance carrier will pay, leaving you to pay the balance, a practice known as balance billing. This can lead to significantly higher out-of-pocket costs for individuals.

Additionally, some insurance plans may not cover out-of-network costs at all, or they may cover only a smaller portion of the expenses. This means that if you choose an out-of-network provider, you could be responsible for a much larger share of the bill.

To summarise, staying in-network will almost always result in lower out-of-pocket costs compared to seeing an out-of-network provider. To avoid unexpected expenses, it is essential to understand your insurance plan, confirm your provider's network status, and make informed choices when seeking healthcare services.

Medicare and Medicaid: coverage may vary by state and program

Medicare Part B may cover Spravato, a prescription medication for the treatment of treatment-resistant depression (TRD) in adults. Spravato is a brand name for esketamine, which is administered as a nasal spray. Medicare Part B may pay for the drug and its administration as part of a doctor's visit, covering 80% of the Medicare-approved amount, with the patient responsible for the remaining 20% and the Part B deductible.

Medicare Advantage plans may also cover Spravato through the pharmacy benefit. When billing for observation time, use the appropriate codes for the services rendered. If needing to bill for prolonged time above 99205 or 99215, use G2212 instead of CPT 99417.

Medicare coverage may vary by state and program. To find out if a specific CPT code is covered in your state, enter the CPT/HCPCS code in the MCD Search and select your state. Review the article, in particular, the Coding Information section. If you need more information on coverage, contact the Medicare Administrative Contractor (MAC) who published the document.

Medicaid coverage may also vary by state and program. Fiscal Intermediaries (FIs)/Medicare Administrative Contractors (MACs) and/or state Medicaid administration determine whether a drug, device, procedure, or service meets all program requirements for coverage.

Verification of Benefits (VOB): outlines what your insurance plan covers, including deductibles, copayments, and the extent of Spravato coverage

Verification of Benefits (VOB) is a crucial step in understanding your potential costs. This document outlines what your insurance plan covers, including deductibles, copayments, and the extent of Spravato coverage.

VOB is a way to ensure the services rendered will result in payment from the insurance company. It is the first step in ensuring payment from both the insurance company and the patient. It is important to verify if the patient's plan is active and if their coverage is current. You will also need to verify if you are in-network or out-of-network with the patient's plan.

The VOB process involves checking the patient's insurance status, copays, deductibles, out-of-pocket maximums, and specifics of what is covered under their plan. This includes verifying the patient's policy status, type of plan and coverage details, claims mailing address, referrals and pre-authorizations, lifetime maximums, and more.

The VOB process is especially important for Spravato because it is a highly-priced treatment and availability is controlled under strict regulations. There are no standardized practices for determining reimbursements, copays, and deductibles.

To obtain a VOB, you will need the following information:

• A copy of the front and back of the patient's insurance ID card
• The patient's first and last name
• The patient's date of birth

You can call the number on the back of the insurance ID card to obtain the VOB. You will be asked for your National Provider ID (NPI) and the patient's information. It is important to tell the insurance representative that you are looking for outpatient mental health benefits rendered in an office setting.

Once you have the VOB, you will know what the patient owes and what the insurance company will pay. This information will help you set realistic expectations and avoid surprises.

Copayments, deductibles, and coinsurance: fixed amounts paid per treatment session, varying based on the insurance plan

Copayments, deductibles, and coinsurance are types of out-of-pocket costs for healthcare. These terms are important to understand when billing insurance for Spravato. Here's how they work:

Copayments

Copayments, or copays, are fixed amounts that you pay for each Spravato treatment session. For example, you may have a $25 copay for each session with your primary care physician. Copayments are usually paid at the time of service and are often printed on your health plan ID card. They can vary depending on your insurance plan and the type of care received.

Deductibles

A deductible is the amount you pay out of pocket for covered medical services or medications before your insurance plan starts to share the costs. For example, if you have a $2,000 yearly deductible, you'll need to pay the first $2,000 before your insurance begins to cover the rest. Deductibles are separate from your monthly premium payments.

Coinsurance

Coinsurance is the percentage of covered medical expenses you pay after you've met your deductible. For example, if you have an 80/20 plan, your insurance will cover 80% of the costs, and you'll pay 20%. The higher your coinsurance percentage, the higher your share of the cost.

How They Work Together

Your health insurance plan may include a combination of copayments, deductibles, and coinsurance. Understanding these terms can help you estimate your out-of-pocket costs for Spravato treatment. Remember that costs can vary depending on your insurance plan and the specifics of your treatment.

Frequently asked questions