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Chronic pain is a public health crisis in the United States, according to the Institute of Medicine (IOM). Studies estimate that 50 million adults in the country live with chronic pain, causing $80 billion in lost wages and lost productivity of nearly $300 billion annually. While pain treatment includes comprehensive evaluation, treatment planning, and care for patients with chronic, disabling pain, health coverage for pain is not comprehensive. Many insurance policies do not cover 100% of the costs of pain treatment. Insurance verification and authorization plays a key role in helping providers and patients understand insurance coverage, deductibles and out-of-pocket costs associated with specific treatments.

Chronic Pain Treatment -What is Covered?

Pain management services include assessment and treatment of a number of conditions (e.g., acute pain, cancer-related pain, low-back pain, musculoskeletal pain, neuropathic pain etc.) and pain comorbidities (e.g., depression). The Affordable Care Act requires health plans to cover certain services and essential health benefits such as prescription drugs and access to pain counseling through family practice physicians. According to a WebMD article, these pain management benefits include:

Patients may have to meet their deductible first and pay a portion of the cost, except for some preventive services.

Medicare plans pay for these essential benefits. Specific services covered under Medicare part B are behavioral health integration services, physical therapy, occupational therapy, manual manipulation of the spine if medically necessary to correct a subluxation, alcohol misuse screenings & counselling, depression screenings, acupuncture for chronic low back pain. Medicare’s plan for drug coverage (Part D) includes Medication Therapy Management programs for complex health needs and opioid pain medication. Medicare Part C, also known as Medicare Advantage, is managed by private insurance companies and combines the benefits of parts A and B, with the same coverage subject to the same rules. Commercial insurance companies or third-party payers have specific rules on the pain management coverage. That’s why patient eligibility verification is crucial. Not verifying insurance will lead to claim denials and loss of revenue.

Verify Patient Eligibility, Minimize Claim Denials

Pain management specialists strive to provide the most appropriate interventional and non-interventional treatments, including prescription pain medicines to help alleviate discomfort and enable patients restore function and improve quality of life. However, patient coverage and benefits vary according to insurance, employer group, and individual plans. Further, some pain treatments may require prior authorization. Verifying patient eligibility is crucial to understand patient insurance benefits.

Delayed or incomplete patient insurance eligibility verification is one of the most common reasons for claim denial in many specialities, including pain management. An MGMA poll listed the most common reasons cited for denials as:

  • Prior authorization not conducted
  • Incorrect demographic information, procedural or diagnosis codes
  • Medical necessity requirements not met
  • Non-covered procedure
  • Payer processing errors
  • Provider out of network
  • Duplicate claims
  • Coordination of benefits
  • Bundling
  • Patient no longer insured

Properly verify insurance coverage, deductibles and out-of-pocket costs associated with treatments. Here are 6 proactive strategies that can help manage/prevent eligibility rejections and denials:

  • Ensure you have an efficient front desk. Have front desk personnel confirm all demographic and insurance information against the patient ID and insurance card. It is very important to verifying this information for completeness and accuracy.
  • Call the insurance companies for benefits and eligibility as much as possible. Check eligibility at each visit can help ensure the patient’s insurance coverage is active.
  • Make sure to obtain the correct copay, coinsurance and deductible information from the patient’s plan. This will help the front desk determine the patient responsibility and collect the payment at each visit.
  • Check which services require prior authorization and also if there are visit or monetary caps. For example, in the case of UnitedHealthcare, pain management for long term and sudden pain is covered only when authorized and provided by a network provider or UnitedHealthcare.
  • Check which services are not covered. Many payers do not cover multidisciplinary pain management programs.
  • Stay updated on private and public payer policies.
  • Know state rules. For e.g., chiropractic care as an essential health benefit in most states, except California, Hawaii, Oklahoma, Oregon, and Utah. Likewise, acupuncture is an essential health benefit only in Alaska, California, Maryland, New Mexico, and Washington.
  • Regularly track submitted claims to detect and address any issues for denials without exceeding the time limit.

AAPM: Ensure Minimum Insurance Coverage for Chronic Pain Therapies

The American Academy for Pin Medicine (AAPM) calls a minimum set of health insurance benefits for people in pain severe enough to require ongoing therapy and also recommends an interdisciplinary clinical approach that recognizes the interdependency of treatment methods in the treatment of chronic pain. The interdisciplinary approach may encompass some combination of the following therapeutic areas:

  • Medical management
  • Physical therapy
  • Occupational therapy
  • Biofeedback
  • Vocational and recreational therapy
  • Psychological counseling (e.g., CBT)
  • Complementary and Integrative Medicine

The AAPM states:”In all tiers of the healthcare system, from the uninsured to those on public and private plans, coverage is needed for comprehensive, interdisciplinary modalities of treatment like CBT, physical therapy, stress management, rehabilitation, complimentary and integrative therapies (CIM) and alternative therapies and medications that are known to be effective and safer than usual care”.

As industry stakeholders and organizations work to address barriers to coverage, pain management specialists can benefit with professional support for insurance verification and authorization. Leading insurance verification companies have experts who can help providers navigate the challenges of verifying patient coverage and obtaining prior authorization to prevent/minimize claim denials.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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