Insurance Policy Exclusions to Watch Out for in 2020

Posted by Elevated Billing on Jan 17, 2020 10:47:09 AM

As we enter a new year and a new decade, keeping up with insurance policy changes is no longer just best practice, but essential to your business.  Sadly, with each new year, insurance requirements continue to increase, and guidelines become more and more strict. To help you stay on top of the changes, we have compiled a list of the current exclusions and requirements we have seen increasing as we head into 2020. Also, at the end of this blog post you'll find a FREE PDF cheat sheet--a simplified list of these bullet points that you can refer to anytime!

1. JCAHO / CARF Accreditation

This is now required more than ever. Anthem policies (CA, OH, VA, and GA) have seen the highest increase for this requirement. Although this does not currently apply to all Anthem policies, it is important to be aware of this restriction when accepting Anthem policies. The following insurance companies have started to include this requirement in their policies as well: Beacon, Aetna, Mountain Health Co-op, HMSA, HMA, EMI, most union policies, BCBS IN, BCBS Federal, and BCBS AR.

Learn more about becoming JCAHO or CARF accredited.

2. 24/7 RN On-Site at Facilities

This is now a requirement for many policies. In previous years, BCBS of AZ were the only ones to implement this requirement, but more and more insurances are jumping on board to enforce this restriction.  Notably: BCBS TX, BCBS IL, BCBS NM, BCBS AZ, BCBS OK, EBMS, most Regence of UT, and many Union Policies. This requirement specifically applies to DTX and RTC levels of care.

3. Residential Facility Coverage Exclusion

One of the more unfortunate trends we are seeing is the exclusion of coverage for Residential Facilities. Luckily, we haven’t seen this exclusion across the board but most often in BCBS AL, BCBS CO, BCBS Kansas City, Iron Workers Union, and Pipe Trader policies. This exclusion will not cover treatment from free-standing residential treatment facilities.  Because this is a policy exclusion, single case agreements are no longer viable options in these situations.

4. Exclusions for Recovery Residence

Unlike standard treatment facilities, living arrangements such as halfway houses, sober living facilities, foster care and guardianship are still considered to be standard exclusions for many commercial insurances. This is often a general exclusion for some major UHC and BCBS policies, so due diligence and thorough research into policy-specific requirements are suggested before attempting to bill for these situations.

5. Long-term Care Diagnoses Denied Coverage

Long-term care diagnoses such as Autism spectrum disorders and personality disorders are not always considered to be exclusions. However, obtaining authorization for these specific diagnoses has been extremely difficult and often unsuccessful. Regrettably, the common thought process seems to result in: "If the disorder can be treated with medications the chance of authorization is higher, if the disorder cannot be treated with medications, authorization is most likely to be denied."

6. Exclusion of Alternative Treatment Methods

 Non-traditional treatment such as- recreational therapy, equine therapy, art therapy and wilderness programs have been labeled as ‘not evidence-based’ treatment and frequently excluded from most commercial policies. We encourage you to research each situation thoroughly before attempting to bill.

Unfortunately, it is impossible to judge exactly which exclusions will apply to each policy. And of course, this list is not comprehensive! It's only the common trends in exclusions and restrictions which we have seen changing with increasing frequency, and expect to continue into 2020. More and more, they are becoming the rule and not the exception among major insurance policies. We want you to be informed, and aware of the changes that impact your business!

That's why we developed this FREE Policy Requirements Cheat Sheet! A simple, one-page document that you can refer to anytime, to make sure you're staying on top of this year's trends!

Get your FREE PDF 2020 Policy Exclusions download!

Remember, every policy has different requirements, exclusions, and restrictions. This is part of what makes billing so complicated and frustrating! To speak to our team of billing experts, and learn how we can help YOU through the billing process, contact us at (385) 212-4004 or 

Topics: Behavioral Health Billing, Behavioral Health, Insurance Billing, Mental Health, Community Mental Health, Behavioral Health Professional, Elevated Billing, Community Substance Abuse Treatment