Insurance Coverage for Wilderness Therapy – May 2019 update

This blog entry is available to download -please consider sharing with current and former clients and their families who may be interested in insurance reimbursement for their OBH treatment: Insurance Coverage For Wilderness Therapy_OBH Council.  Full document also follows below:

Insurance Coverage for Wilderness Therapy

In the past twelve months, there have been some important strides in receiving insurance reimbursement for intermediate outdoor behavior health (OBH) programs, sometimes referred to as “Wilderness Therapy.” The insurance landscape is fluid and ever changing, requiring regular updates for current and past parents of wilderness therapy families. Please visit the OBH Council website’s blog page for ongoing updates.

Some Background

Insurance coverage is continually changing, covering greater services, particularly regarding mental health and substance abuse coverage. Understandably, insurance companies only recognize established mental health practices, which historically fell generally into inpatient hospitalization and outpatient therapy. As mental health professionals establish a new and effective treatment modality, insurance companies begin recognizing and authorizing it for coverage. This can be a slow process at times, and it’s where we are currently at with OBH programs.

Intensive outpatient care and partial hospitalization care were some of the first major mental health services to be recognized and reimbursed by insurance companies. Both of these levels of care offer intensive mental health treatment for a number of hours a week, but release patients back home for sleep, school, and other daily activities.

One of the next treatment services to receive recognition and coverage by insurance companies were residential treatment centers. These facilities offer longer term intermediate care for patients suffering from chronic mental health issues. The passage of the 2008 Mental Health Parity and Addictions Equity Act also played a role in health insurance carriers beginning to offer coverage for residential treatment facilities.

Currently, OBH programs and healthcare advocacy firms are working with insurance companies to collect the necessary information for OBH programs to be recognized and clearly established as authorized for coverage. There is overwhelming evidence from mental health professionals and researchers showing that OBH programs are beneficial (particularly for adolescents and young adults). Through the ongoing hard work and dedication from researchers, OBH providers, healthcare advocates, and attorneys, OBH care and insurance providers are slowly gaining traction and more and more families are receiving insurance reimbursement support.

Insurance Claims and Billing

A notable step forward for OBH care was The American Hospital Association’s recognition of OBH care as a viable form of treatment, and the National Uniform Billing Committee’s establishment of an insurance billing code for OBH care in July 2016. This update, and the corresponding change to the UB-04 billing manual, show that OBH care has been recognized by both the general medical community and federal organizations as a valid treatment modality.

With this valuable step, several healthcare advocacy firms have helped implement the new revenue code (“Outdoor/Wilderness Behavioral Healthcare, Revenue Code: 1006”). One such healthcare advocacy firm, Denials Management, Inc., reports that they have obtained over seven million dollars in reimbursements for families of wilderness patients between 2014 and 2018. They anticipate this amount to rise as the updated revenue code continues to pave the way for widespread recognition of OBH care.

Scientific Research

Historically insurance providers have denied OBH treatment claims classifying it as “dangerous,” “experimental,” or “unproven”. However, nothing could be further from the truth. Today’s OBH Accredited programs offer a safe and secure treatment modality for adolescents and young adults. The Outdoor Behavioral Health Council (OBH Council) was founded in 1996 to advance the field through establishing best practices with effective treatment and using evidence-based research. Through this research the OBH Council has been able to work with insurance companies and provide the necessary evidence showing how OBH Council programs are safe and effective.

The research conducted through the OBH Council and other independent researchers all point to the same conclusion—OBH Council programs are a highly effective treatment modality for teens and young adults. In fact, since 2012, over 40 independent, peer reviewed studies have come to the same conclusions—that OBH care from an OBH Council program is effective. In fact, many of these studies show OBH Council programs are more effective than other forms of intensive treatment, while costing less for patients! A recent study concluded that care from an OBH Council program was up to three times more effective than treatment as usual for mental health and substance abuse patients. Not only are OBH Council programs more effective, the treatment completion rate for OBH Council program patients is higher than that of patients in other levels of care. Treatment completion is a key indicator of positive outcomes, and OBH Council programs have a 93% completion rate compared to 42% for treatment as usual. All of these proven benefits occur while costing less money than alternative forms of treatment. These cost savings alone are significant: OBH Council programs are (on average) $8000 less expensive while being 2.75 times more effective than treatment as usual. It’s with these types of results and ongoing research that the OBH Council continues to stride in its collaborative efforts with insurance companies in providing more effective, and affordable mental health services to their clients.

Legal Action

During this process of recognition by insurance companies some families have needed to take more immediate steps to address their current financial struggles. This has resulted in legal actions. There have been several recent decisions concerning whether or not a health insurer’s decision to deny OBH care violates the terms of the Mental Health Parity and Addictions Equity Act (MHPAEA). In many of these cases, federal judges have found that an insurer’s action to blanketly exclude OBH care from coverage, while having no similar limitation on intermediate medical/surgical care, appears to violate the MHPAEA’s requirement that mental healthcare and medical care be treated similarly.

One such case was a class action suit brought against Regence Blue Cross and Cambia Health Solutions, which resulted in these insurers offering a settlement. Several other cases are being argued individually and are still pending judgment, which will further outline the legal responsibilities of insurers in regard to OBH care. Other cases that were decided in favor of OBH programs include:

  • Michael D. v. Anthem Health Plans of KY., Inc
  • Z. v. Regence BlueShield
  • Vorpahl v. Harvard Pilgrim Health Insurance Co.
  • H. v. Microsoft Welfare Plan • Buchanan v. Magellan Health, Inc.

There are several other lawsuits currently pending in district courts nationwide that involve insurance coverage of OBH programs. We will keep an eye on these cases, and update this blog periodically when more information becomes available.

What does this mean for you?

There are many OBH programs out there, but few belong to the OBH Council due to the rigorous requirements of ongoing research and accreditation that indicates a commitment to the highest treatment standards of the field. If you are considering placing your child in an OBH program, it is highly recommended you consider a program that is an accredited OBH Council program. The OBH Council has over 15 years of risk management research showing adolescents in an OBH Council program are two times less likely to visit an ER or doctor than an adolescent at home. It’s for all of these reasons families should seriously consider an accredited OBH Council program.

If you are considering placing, or have already placed your child in an OBH program and are seeking insurance reimbursement, consider hiring a healthcare advocate to help you navigate the complexities of insurance reimbursement. Some OBH programs provide recommendations or healthcare advocates can be found through online searching. Some healthcare advocacy firms charge based on a percentage of the money obtained from your insurance company, while others charge a flat rate. Either way, healthcare advocacy firms can be highly beneficial in determining if you are eligible for insurance reimbursement, and then working with you through the claim’s procedure.

Working with insurance companies for reimbursement for OBH care can be a disheartening process, but you are not alone. Your child’s program, the OBH Council, dedicated healthcare

advocates, attorneys, and parity advocates are there to help. One of these advocacy groups is the Kennedy Forum. This group focuses on fully implementing the parity law and working with insurance providers to guarantee equal access to mental health care. I encourage all to consider getting involved and contact a group like the Kennedy Forum and see what you can do to help.

We are seeing changes in insurance coverage for OBH programs, and there is still more work to be done. With the dedication of all those involved, we truly believe it’s not if, but when insurance companies recognize the high effectiveness of OBH programs and the value saved, they will provide full coverage for them as any other intermediate mental healthcare treatment.

Written by the OBH Council Chair

With special thanks to Dr. Michael Gass from the Outdoor Behavioral Healthcare Research Center for the research information outlined in this blog and Denials Management for the overturned information included in this blog.

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