Cavalier40
Guest
I am the billing director for a family of Substance Abuse facilities. We have 2 in Florida and 1 in Pennsylvania. For BCBS we are in network in PA, but 100% out of network in FL.
We recently just expanded one of our Florida facilities to accept detox and non hospital inpatient rehab.
We recently attempted to get a prior auth for a BCBS FEP plan in Florida, but we were told that in order to go to detox, they had to do an initial assessment, have both full treatment plans and aftercare plans all before they are even admitted. Then the patient has to acquire a case manager in their own and wait 72 hours all before admission. Medical Management (who does FL FEP auths) said this policy started Jan 1, 2016.
We do not have this issue in PA both because we are in network and FEPs use the substance abuse carve out of the host plan, so we go through highmark.
I know they are trying to discourage patient of going to an out of network facility (as they already do by paying to the patient) However if this policy is not in effect for in network clients, is that a violation of PPO law? Would state PPO laws even matter since FEPs are covered under ERISA? Would I have a claim under federal parody laws if voluntary medical inpatient stays do not go through the same scrutiny?
72 hours is a long time in the life of an addict.
We recently just expanded one of our Florida facilities to accept detox and non hospital inpatient rehab.
We recently attempted to get a prior auth for a BCBS FEP plan in Florida, but we were told that in order to go to detox, they had to do an initial assessment, have both full treatment plans and aftercare plans all before they are even admitted. Then the patient has to acquire a case manager in their own and wait 72 hours all before admission. Medical Management (who does FL FEP auths) said this policy started Jan 1, 2016.
We do not have this issue in PA both because we are in network and FEPs use the substance abuse carve out of the host plan, so we go through highmark.
I know they are trying to discourage patient of going to an out of network facility (as they already do by paying to the patient) However if this policy is not in effect for in network clients, is that a violation of PPO law? Would state PPO laws even matter since FEPs are covered under ERISA? Would I have a claim under federal parody laws if voluntary medical inpatient stays do not go through the same scrutiny?
72 hours is a long time in the life of an addict.