If your healthcare and mental health company is using Spravato for treatment, billing insurance for Spravato can be tricky. With the right mental health consulting services, you can learn how to bill private insurance much more easily.
Spravato REMS
When billing insurance for Spravato, companies must follow the FDA’s Risk Evaluation and Mitigation Strategy (REMS). This means that all Healthcare settings must be certified to receive, dispense, or receive reimbursement after treating patients with Spravato.
Pharmacies from which healthcare companies receive Spravato must also be certified accordingly.
Inpatient healthcare settings must complete and submit an inpatient healthcare setting enrollment form prior to billing insurance for Spravato. However, they are not required to provide patient monitoring forms.
Outpatient healthcare settings must complete and submit an outpatient healthcare setting enrollment form prior to billing insurance for Spravato and are required to provide patient monitoring forms.
Coverage and Acquisition Considerations
Before billing private insurance companies for Spravato, you need to ensure that all of your coverage and acquisition considerations are in line.
Insurance
First, you need to figure out what type of insurance your patient has. From there you have to determine if the billing provider is considered an in-network provider for the plan or a participating member. you also need to review whether they have Medicare or a non-medicare plan.
Type of Coverage
Second you need to figure out the type of coverage that will be applied to the Spravato treatment. it might be covered under medical or pharmacy.
Your company will need to figure out if the payer requirements specifically indicate where the drug and its administration have to be provided or whether there is a Behavioral Health Organization aspect to the treatment.
It is important to figure out if your office is considered an in-network for the insurance company and all of the codes that are contracted to everyone involved in Spravato administration.
Pre-Approval
Be sure to check any pre-approval requirements. Sometimes, a patient requires appropriate clinical documentation, which you may have to provide or contract through a referral before you can administer the treatment, let alone bill for it. You might also require a letter of medical necessity or additional information based on the insurance company.
Procurement
Check to see if the insurance policy determines how the Spravato is to be procured and what method it allows. it might need a buy-and-bill option or a REMS-certified pharmacy.
Codes
Finally, billing insurance for Spravato means that you have to figure out what specific drug and service codes have to be utilized and whether there are ICD-10, CPT, or PSPCS codes that need to be billed.
You will also need to determine whether you have filled out the CMS-1450 or CMS-1500 forms correctly. If you are complying with Evaluation and Management codes, they need to be aligned with the type of work that was performed.
Tip: Prior to using Spravato treatment for your patients, you might consider making sure that all of your drug and service codes are included in the payer contract, which is something that a consultation service can help you with.
Billing Insurance for Spravato: Evaluating Access
Once you have gone through your coverage and Acquisitions considerations, you need to determine the type of access that is covered by a medical benefit or a pharmacy benefit. This will impact the way you acquire Spravato and how you bill for it.
Medical Benefit
If the patient’s medical benefits cover Spravato, then the procurement type that you use is the buy-and-bill method or REMS Pharmacy.
Buy-and-Bill
The buy and bill method is where your practice directly acquires Spravato and then you build the insurance company by submitting a medical claim after the drug has been purchased and administered.
The policy that a client has will dictate the coding you use whether it is a bundled billing for the drug and the administration of that drug together or a non-bundled version where they are billed separately.
For buy-and-bill, the codes that the payer policy dictates be used for reimbursement are either G codes for bundled billing or an S code, E/M Codes, Prolonged Services codes, or Prolonged Clinical Staff Service codes for non-bundled billing.
REMS Pharmacy
For this method, the pharmacy benefits cover the cost of the drug and that has to be administered at an approved REMS site where service codes are used to bill for the administration but not the drug cost.
For REMS pharmacy, the codes are E/M Codes, Prolonged Services codes, or Prolonged Clinical Staff Service codes.
Pharmacy Benefit
If the patient’s pharmacy benefits cover Spravato, then the procurement type that you use is the local REMS-certified pharmacy and/or a specialty pharmacy.
For REMS pharmacy or specialty pharmacy, the codes are E/M Codes, Prolonged Services codes, or Prolonged Clinical Staff Service codes.
Overall, figuring out how to bill a private insurance company for Spravato means an in-depth understanding of the purchasing and administration requirements, REMS certifications, and more. Working with C4 Consulting can give you access to trained professionals who can help you easily navigate this information and determine the fastest way of billing insurance for Spravato.
Contact our team today to schedule your consultation.
