Insurance Coverage Tips from Utilization Review Nurse Lisa Bozzuto, MEd, RN

For more than 20 years, Lisa Bozzuto, MEd, RN, has been helping patients at the Austen Riggs Center. First, as a psychiatric nurse and most recently as the full-time Utilization Review Nurse, where she advocates for patients and works with insurance companies to help secure reimbursement for medically necessary treatment at Riggs.

We sat down with Bozzuto to ask her about her role, how she interacts with insurance companies, and what patients and their families can expect when it comes to insurance coverage for Riggs treatment.

A: Ideally, before a patient comes to Riggs for their admission consultation, they provide us with information about their health insurance company and plan. I call the insurer and ask whether the prospective patient has an out-of-network benefit for residential mental health on their plan (and, if they are coming from outside Massachusetts, I ask if they have an out-of-state benefit). I document the information the insurer provides. 

On the day of admission, patients and their families meet with members of our business office to go over information related to the payment for treatment. I join these meetings to introduce myself as the Utilization Review Nurse, provide my contact information, and relay what I have learned from their insurer regarding their coverage. Many times, patients and their families may already know this information.

I inform patients and their families that I will be contacting their insurer the next day to make a case, based on the patient’s clinical presentation from the admission consultation, that it is medically necessary for the patient to be in treatment here at the Austen Riggs Center. Riggs uses the Level of Care Utilization System (LOCUS), a nationally recognized standard, to determine medical necessity, but each insurer uses their own set of medical necessity criteria. Once I have a determination about coverage, I relay that information to whoever the designated contact person is (sometimes the patient, and/or if authorized by the patient, a parent or family member). 

A: Patients and their families need to provide us with information about who their health insurer is and what insurance policy they have. The more familiar they are with their policy and their benefits, the better. They can expect us to communicate openly and honestly about the process and we expect that they will likewise communicate openly and honestly with us.

 

A: As I described above, I do the initial screening to see if someone has an insurance benefit for treatment at Riggs. 

After admission, I contact the company to try to obtain authorization for residential treatment. If this is approved, I subsequently conduct concurrent reviews for as long as the company deems the treatment to be medically necessary.

We take a strong and unapologetic stance about a patient’s right to equal coverage when they have a residential benefit on their plan. The creation of my role came about because there was a growing need for a dedicated staff member to deal with insurance companies in this manner and Riggs made a strategic decision to allocate resources to advocate for mental health parity, both here in our specific facility and more broadly in the field of mental health.

I also notify patients and/or their families when coverage is denied. Denials can happen for a variety of reasons including changes to lower levels of care in our continuum of treatment, being away from the Center for non-medical reasons, or improvement in the patient’s mental health status. But, whatever the case, I am always available by phone to consult and provide information to the best of my ability related to insurance matters.

A: This can vary greatly depending on an individual’s insurance policy and the insurer’s responsiveness. Generally, we will know if someone is covered within days of admission. How much coverage someone receives depends on a number of factors. When we do a benefit check, an insurer may tell us that they will cover a certain percentage of their “allowable amount.” The difficulty is that they do not disclose what their allowable amount is upfront (or ever). For example, let’s say we bill $1,500 a day for our treatment. If an insurer says they will cover 60% of their allowable amount and their allowable amount is only $800 a day, then they pay $480 a day for treatment coverage.

It is a point of frustration for us and for patients and their families that sometimes the actual amount of coverage is unknown until patients and their families receive a check from their insurance company. This often takes an extended period of time, both because we bill on a monthly cycle and because the response rate of insurance companies varies widely. 

It is important to note that the financially responsible individual must keep the account current at all times, regardless of potential insurance coverage.

A: Our research shows that, although the Austen Riggs Center is not an “in-network provider” with any health insurance plans, more than 90% of patients with insurance policies offering out-of-network benefits receive coverage to support some of the cost of treatment. On average, these patients are approved for 60-90 days of coverage (60 = median number of days, 90 = mean number of days). Payment is typically based on insurance companies' "usual and customary" daily rate. 

Beyond that, insurance companies seem to be more generally aware of mental health parity laws, which helps the case for getting patients coverage. It does vary by company and state, but we are seeing most patients get some coverage for treatment at Riggs, which is an improvement and a positive trend. The length and amount of coverage still varies widely but we’re seeing more patients being covered for more days of treatment as well.

The less encouraging trend is that the systems at many insurance companies are much more automated than they used to be; having a conversation with another person makes it easier to advocate for our patients. When there is a dedicated case worker that I’m able to connect with, a relationship can be established, and meaningful conversations can occur. 

A: Advocating for the patients. Insurance companies are often obligated to cover mental health treatment, but it takes an advocate at times to make them deliver on their policy or authorize medically necessary treatment. When someone has a medical concern, like diabetes, it can be easier to obtain an authorization for treatment. Mental health parity laws are clear that it should not be a different story when it comes to mental health, but sometimes it takes a conversation from either me or a member of the treatment Team to get them to recognize that physical health and mental health are both vital to the overall health and well-being of the person. I’ve learned a lot from my colleagues, especially Drs. Plakun and Gallagher, about how to be a proponent for equitable coverage and am very grateful for the work that they are doing.