Don’t Make Your Problems Worse

Is This Rehab For Real?

Part 1 of 2

©Grand View Research

The addiction and mental illness treatment industry is an unregulated $140 billion business¹ with its share of grifters and 1–800 toll-free call centers standing by to promise you anything to get your credit card number. I can’t tell you how many times families have told me horror stories about being swindled out of their hard-earned money which only makes an impossibly horrific situation worse. So who warns the families terrified to the point of doing anything they’re told to save their loved one?

That 3AM call 14 years ago that my loved one was in an addiction-fueled crisis not only changed my life, but also made me who I am today — from producer to interventionist and treatment placement specialist working with families who also get that life-altering call and have no idea what to do. I was lucky because I had a friend in the treatment world who knew exactly what to do. Most families are not that fortunate.

Today, I now work with vulnerable and terrified families — just like mine was — in navigating the confusing world of treatment, health insurance and recovery, while protecting them from the scammers and grifters who take advantage of the uninitiated who don’t know any better.

The following are some rules so they do know better when determining if a particular rehab is the right one for themselves or their loved one, especially when that rehab is trying just a little too hard to get their business.

Let’s Start With What You Can Afford

Treatment professionals, as well as the U.S. Surgeon General, insist that a one-year treatment plan that begins with a 90-day formal treatment regimen offers the best opportunity for one to reach sobriety and maintain a recovery lifestyle. But, before we get into the weeds of what you should ask a facility admissions person or sales rep, let’s be straight on one immutable law of rehab physics that applies to all treatment facilities — how to pay for treatment.

©2023 The Right Rehab, LLC Source SAMHSA²

There are 6 ways to pay for treatment

There are 6 general ways to pay for treatment:

1. Private Pay (cash or credit card)
2. Private Insurance (Blue Cross, Aetna, Cigna, United HealthCare, etc.)
3. Public Insurance (Medicare, Medicaid, Tricare, etc.)
4. Public Assistance (federal, state or local sponsored treatment)
5. Courts (court-ordered treatment programs)
6. Scholarship (several facilities have scholarship programs)

Private Pay (Cash)

Private pay is the only way to get 90-days of formal treatment at a rehab. Do you have the resources to Private Pay (cash, credit card) for treatment and what is the facility’s cash price per day? Per month? If you pay with cash, does the facility offer discounts if you pay the whole sum upfront or over subsequent months of treatment?

Does the facility offer payment plans? For those who wish to pay cash, but need a loan to do it, some facilities suggest loan companies just for that purpose. Does this facility recommend any?

Above all else, be certain to get confirmation of your payment arrangement.

Think Private Insurance Will Save Your Ass? Not So Fast…

“But I have insurance, why do I need to pay anything?” is a refrain I hear constantly. Just because you have a health insurance policy doesn’t mean you don’t need cash — sometimes a lot of it.

Rule of Thumb: private health insurance covers the therapeutic (the therapy) portion of one’s treatment. Any ancillary costs such as sober living, food & living are not covered. That is up to the patient or the financial guarantor of the patient’s treatment. Note: this is regarding private insurance as opposed to some veterans programs (i.e.; the Community Care Network) that will cover all expenses, including transportation.

If you plan to use your private health insurance — for which you personally pay the whole premium or it is subsidized through your employer — facilities ask for the outstanding deductible and maximum out-of-pocket to be paid to them upfront. Most often, double that figure if the facility is out-of-network with your insurance. There are also some facilities that need to add on a deposit for housing costs that will likely be needed further into the treatment cycle.

I have had clients with a policy, but with no out-of-network benefits, so they are stuck with going to an in-network facility which may not be the best option for their treatment. There are also policies that can only be used at in-network facilities in their state of residence. On top of that, some insurance carriers don’t allow for detox and residential treatment — the only treatment they will cover is outpatient.

Anyone’s knee-jerk reaction is “how can the facilities get away with this?” Understandable reaction, but don’t blame the facilities, at least the ethical ones. Their hands are tied by the insurance companies.

My point is this: before you purchase a private health insurance policy, make sure it comes with a more than adequate behavioral health package for substance use AND mental disorders. And be damned sure to make sure that any facility you are thinking of using is totally covered by your policy for all stages of behavioral health treatment and is in-network or out-of-network with your insurance policy.

Here’s How It Works

Assuming you have health insurance that has Behavioral Health coverage and you wish to use it at the right rehab for yours or a loved-one’s addiction and/or mental disorder treatment, confirm the stages of treatment that the facility offers.

You give the facility your insurance information which they call in to your insurance company. Your insurance company gives the rehab a VOB (Verification of Benefits) which verifies the terms of your policy as well as your outstanding Deductible and Maximum Out-of-Pocket that must be paid upfront (your individual OOP, not family) to the facility before or upon admission.

When the Rehab is In-Network With Your Insurance

When the facility contacts you regarding what your insurance will cover, verify if the facility is in-network or out-of-network with your insurance. Assuming they are in-network, ask the facility for their recent history with your insurance company for the number of days they have been authorizing for the following stages of treatment:

1. Detox (Detoxification or stabilization prior to treatment)?
2. RTC (Residential Treatment Center)?
3. PHP (Partial Hospitalization Program)?
4. IOP (Intensive Outpatient Program)?

If your insurance company routinely stops authorizing RTC (residential treatment) prior to the standardized end of that stage, day 30:

1. To complete 30-days of RTC, is the patient charged private pay rate until day 30?
2. Is the patient dropped down to PHP level of care (outpatient)? If yes, does the facility keep the patient in the RTC setting until day 30? Does the facility charge a housing fee for those days until day 30?
3. If the patient is dropped down to PHP level of care and moved out of the residential setting, is he moved to a separate sober living/housing setting before Day 30? If yes, what is the housing fee for the new living setting and is there a limit for the amount of days the patient can stay there?

When the Facility is Out-of-Network (OON) with your insurance company

Note: with an OON facility, the individual & family’s Deductible and Out-of-Pocket are higher (could be double) versus an In-Network facility.

When the facility gets a VOB from the insurance company, one of two options should occur:

1. The facility projects that the total of the a) unmet individual maximum out-of-pocket fee that you pay upfront, plus b) the reimbursements they will receive from your insurance company, plus c) any housing fees you will pay DURING treatment. If that total is SATISFACTORY, that will be the cost of the patient’s stay, not including any medications or the patient’s personal ancillary items.
2. The facility projects that a) the total of the unmet individual maximum out-of-pocket fee that you pay upfront, plus b) the reimbursements they will receive from your insurance company, plus c) any housing fees you will pay DURING treatment. If that total is NOT SATISFACTORY, you are faced with the following options to still receive out-of-network benefits DIRECTLY from your insurance company:

Photo by Kostiantyn Li on Upsplash

YOU PRIVATE PAY the facility either upfront or according to an agreed upon payment schedule and one of the following will occur:

1. As a courtesy, the facility files with your insurance company on a WEEKLY basis DURING TREATMENT for out-of-network reimbursements to be SENT TO YOU DURING TREATMENT.
2. As a courtesy, the facility files with your insurance company AFTER treatment is completed for your out-of-network reimbursements to be SENT TO YOU.
3. As a courtesy, the facility recommends a 3rd party company that will do the filing for you for a fee AFTER treatment is completed.
4. AFTER treatment is completed, the facility gives you a SUPERBILL and leaves filling for out-of-network benefits with your insurance company up to you.

By utilizing your out-of-network benefits, getting treatment at a facility which normally is outside of your financial capability becomes a real possibility. For instance, a facility that charges $45,000 per month could be actually $22,500 or less per month when factoring the out-of-network reimbursements. Does that mean that particular facility is reachable by most families? No, not by a longshot, but it does make it more reachable for some.

Now that payment options have been addressed, Part 2 arms you with answers you will need to determine if a facility is the right one for the individual who needs treatment or is it an imposter that only wants to rip-you-off.

Walter Wolf is the pen name of a 30-year veteran of the movie and television industry who produced studio and independent films and television throughout the United States, Australia, and South Africa. That all changed in 2010 with one 3 A.M. call that a family member was in crisis due to addiction. Today, he is an interventionist who matches adults and adolescents with the optimum treatment program and facility for their particular diagnosis, demographics, financial and personal needs. In order to demystify and explain in layman terms what treatment is and how to get it, Wolf wrote The Right Rehab which became the only step-by-step guide for vulnerable families navigating the confusing world of addiction and mental disorder treatment, health insurance and recovery.

SELECT for Reviews

The Right Rehab: A Guide to Addiction and Mental Illness Recovery When Crisis Hits Your Family

Footnotes

¹ Grand View Research, U.S. Mental Health and Addiction Treatment Centers Market Size, Share & Trends Analysis Report By Disorder Type (Mood Disorder, Anxiety Disorder, Psychotic Disorders), By Treatment Centers, By Age Group And Segment Forecasts, 2023–2030. https://www.grandviewresearch.com/industry-analysis/us-mental-health-addiction-treatment-centers-market-report

²SAMHSA, Center for Behavioral Health Statistics and Quality. (2022). Results from the 2021 National Survey on Drug Use and Health: Detailed tables. Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/report/2021-nsduh-detailed-tables