December 2024: ROC Monthly Masterminds Call
2024 Reimbursement Outlook: Key Changes, Challenges, and Trends to Prepare For in 2025
2024 Reimbursement Outlook: Key Changes, Challenges, and Trends to Prepare For in 2025
As we approach 2025, we're reflecting on the key developments in the behavioral health marketplace, including policy changes, veterans' coverage, and updates with providers like Ambetter, MHN, and Healthnet. We also discussed emerging trends, such as the growing demand for treatment closer to home, evolving reimbursement trends, and geographic limits on access to care.
Thank you to everyone who joined us for a thoughtful discussion as we explore the major trends of the past year and look ahead to what's coming next for the industry.
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Additional Topics Covered
Top 3 Denials Reasons
At Hansei, we have identified the top three reasons for denial rates, which include:
Inconsistent Documentation/Charts: Discrepancies in medical records can lead to coverage denials.
Subjective CWA & COW Scores: When nurse assessments yield low subjective scores that don’t match physical documentation, it can complicate the process of getting insurance approval, particularly for cases requiring authorization. This misalignment can lead to denials or delays in reimbursement.
Lack of Clear Justification for Care: If the documentation doesn't clearly explain why it's unsafe for the patient to leave for care (e.g., risk of relapse), it may result in denial.
Utilization Review Overview
Recent changes in utilization review (UR) processes, based on our data, indicate that reviews are conducted as follows:
30% live interactions
10% voicemails
60% via fax
Typically, an advocate from your organization or a third-party billing partner connects directly with an insurance agent or leaves a message for the patient. However, due to operational cost-saving measures, many payer organizations now limit human involvement and rely on third-party reviewers. This shift reduces personal interaction, which can be critical for humanizing the patient’s case by including details like family history and background.
For non-voice URs, it’s crucial to document this contextual information in the medical record to provide a comprehensive view of the patient’s case. Thorough documentation remains the foundation of successful reimbursement.
Additional Payer Updates
Evernorth
Effective Jan 1, 2025, Evernorth is updating its prior authorization requirements for PHP services. This means prior authorization will not be required for PHP LOC for your patients with coverage under most Evernorth plans. However, a small number of plans will still require preauthorization. Dates of service before Jan 1, 2025, may require pre-authorization.
BCBS YUQ Policies Impacting Substance Use Treatment Reimbursement
Beginning January 1, 2025, BCBS plans in certain states will implement new out-of-state (OOS) coverage limitations. These policies may hinder access to care for members traveling or residing near state borders.
Past Resources on 2025 payor changes mentioned in our discussion:
Alabama: Some plans have OOS restrictions (reference page 5) https://www.bcbsal.org/bb/2025ste-87.pdf?frm=alabamablue.com.
New Jersey: Some plans limit OOS; see "Service Area Available" for each offered plan https://nj.gov/treasury/pensions/documents/hb/oe2025/2025-Horizon-shbp-state-overview.pd.f
Montana: Some plans limit OOS (Blue Preferred Security Individual Plan PPOs) https://www.bcbsmt.com/bb/ind/bb_cpsh30ppoimtp_mt_2025.pdf#:~:text=OUT%2DOF%2DSTATE%20SERVICES.%20Notice:%20Effective%20January%201%2C%202025%2C,coverage%20for%20services%20provided%20outside%20of%20Montana.
We’ll see you next month to pick up where we left off and kick off 2025 to a good start! In the meantime, join our Facebook Group!