Head Inside Mental Health
Todd Weatherly, Therapeutic Consultant and behavioral health expert hosts #Head-Inside Mental Health featuring conversations about mental health and substance use treatment with experts from across the country sharing their thoughts and insights on the world of behavioral health care.
Head Inside Mental Health
What Your Insurance Won’t Tell You About Paying For Treatment with Travis Herman, Healthcare Consultant
The question families often have to ask isn’t about diagnosis—it’s about dollars. We pull back the curtain on how mental health and substance use treatment actually gets paid for, from the moment you ask “do you take my insurance?” to the day a claim is approved, denied, or appealed. With Travis Herman, we map the terrain: building a real clinical profile, matching to the right level of care, and threading the needle through deductibles, coinsurance, and out-of-network pitfalls.
We get specific about carve outs that shrink behavioral health networks, marketplace HMOs with no out-of-network benefits, and plans that fund PHP or IOP but exclude residential care. You’ll hear why timing matters—especially when deductibles reset—and how a solid Verification of Benefits protects you from surprise bills and false assumptions. We also explore practical tools families can use right now: single case agreements to align rates, payment plans within in-network contracts, medical lending options, scholarships for veterans and first responders, and the role of superbills for programs that can’t bill insurance directly, like many wilderness models.
Most important, we center clinical fit over convenience. If legal issues restrict travel, we tailor in-state options. If co-occurring disorders complicate recovery, we prioritize programs licensed to treat the full picture. And if past short stays failed, we design longer, stepwise care that documents medical necessity and improves the odds of sustained stability. The takeaway is clear: find the right care, for long enough, with a plan that uses insurance strategically instead of letting insurance steer the whole journey.
If this conversation helped you see a path forward, follow the show, share it with someone who needs it, and leave a review with the one insurance question you still want answered.
Hello, folks. Thanks for joining us on Head Inside Mental Health, featuring conversations about mental health and substance use treatment with experts, advocates, and professionals from across the country sharing their thoughts and insights on the world behavioral health care. Broadcasting on WPBM 1037, the voice of Asheville, independent commercial-free radio. I'm Todd Weatherly, your host, therapeutic consultant, behavioral health expert. And with me today is a dear friend, uh, Mr. Travis Herman, Healthcare Consultant with Align Consulting Group here in our area in Western North Carolina, where he has been for a very long time. And um, you know, I don't want to say he's old or anything, but I would like to say that he is a man of great experience that when I start to figure out and can't find a resource I need, a lot of times he's a man I'll call. I greatly respect his time and experience in the field. Mr. Travis, welcome to the show and thanks for joining us.
Speaker 1:Thank you. That's a great introduction. Appreciate that. Yeah, and uh it's a symbiotic relationship. Whenever I get in a pickle and I need a resource, I I give you a call. So it works out. Yeah. Um, yeah, and uh I I'm getting older, uh, but I'm definitely a dinosaur uh in this uh industry, uh, especially being kind of in the in the representative sales, you know, uh world. Um not many people hang around in that space for very long. And the ones that do, um we're either uh gristled and and burned out, or um or there's something in inside of us that just keeps us uh trudging along, trying to help people uh guide them to you know uh programs that that make sense for that.
Speaker 2:Yeah, well you've you've certainly kept you certainly kept your vitality in the process of all that. And I, you know, I'll I'll I'll add on to that the the caveat that despite the fact that you would you channeled your role into outreach and business development, I know that you started like I did in direct care. Um and I can I can say, you know, the the thing that we run into and I run into as a consultant all the time is that you've got a lot of very talented providers out there. You've got therapists and doctors and psychiatrists and the whole nine yards, but none of those people really leave their area. So the number of people that really do know what's out there and get around and look at programs and have relationships and know people, it's a very specified role. A lot of times that's reserved for ed consultants. There are only a few business development folks out there in the world that I would consider like at that tier who really have been in the field long enough and have had relationships that they can know resources even when it's not their program they're referring to. You are one of you are one of a handful of people I would rely on for that. And and and that is a major compliment coming from me or any consultant, frankly.
Speaker 1:So I appreciate that. Yeah, and you're right. You know, the providers that are out there um very talented in what they do, but uh when they when they do have a situation where somebody needs a higher level of care, they only know what they know. Um they're they're not leaving their office to go tour. Well, very few practitioners leave their office to go tour programs.
Speaker 2:And so often we're gonna do it very much, right?
Speaker 1:Right. Uh have the availability, all the all those things, yeah. Uh and and the ones that that do um, you know, or the ones that are that that are even trying to point people in the right direction, often the the things that they're referencing are either places they used to work at, um, which could have changed since they were last there. Um, or it's a program that they've heard tell of, right? So um, so they're kind of working off of old old data, whereas um part of your yeah, part of your requirements um to do what you do, you you're required to visit um you know programs every every year, every two years, uh a certain number. And then for me, I did it uh one out of curiosity, but two, as we try to find partners, because we're not, you know, Lakeview Health isn't the right fit for everyone. So if I don't have a I'm gonna date myself, a Rolodex, right, of uh options that check more boxes than than my program does for a particular person. If I don't have that, then I'm really not that great of a resource. I can talk about my program all day long. But if I've got a family on the phone and we've walked through some some conversation and and uh realized that we're not the right fit clinically or geographically or financially, um, I could hang up the phone, right? And and in the conversation and say good luck, or I can say, hey, I know how much time and energy it took to make this phone call. Um let's pivot and and explore uh alternative options that might be a better fit for you or your loved one. And that's actually that's that's actually the fun part.
Speaker 2:Yeah, yeah, absolutely. Well, I mean in reference to that list that you're talking about in terms of fit, you know, obviously we're you know, you talk to a family, you talk to somebody who's in need of care, we're talking about, you know, what therapeutic need, what kind of programming do they need, and you know, what is it? Have they got anything specific you need to address? Is there a medical concern? Is there specialized psychiatric concerns that are part of their profile? Is our program capable of meeting it? But one big ticket item that you and I were talking about before we started our little our interview today was the what does it cost and take my insurance? Right. Um, and I is it first sometimes it's first for families, you know. It's like, look, we got to do something that's right, but we also gotta do something we afford. And you know, you were like, look, we should, we should, I mean, this pro this field in the last decade, you know, you walked into it the uh you were telling me it too in 2008. The difference between the insurance game in 2008 and in addictions care, substance use care, and mental health care versus today is it's it's like night and day. It's still not where we want it to be, but it's a far, it's well ahead of where it was. Um yeah. But it's still so very tricky to navigate. Um, and you end up, you know, you end up in all kinds of scenarios. So you are offering graciously to talk, because I think that you spend actually even probably more time doing this than even I do, and I spend a lot of time doing it. I would love to hear what you've got to say about how to navigate that piece when it comes to finding good treatment.
Speaker 1:Yeah. Well, I hey, I appreciate that. Yeah, I would love to spend some time on that. And and typically sometimes it's first if if the person I'm talking to brings it up out the gate. And I just address it head on. I just say, you know, when they say how much is it going to cost, I say, that's a fantastic question. It really depends. It could be literally everybody hates that eight. Right. It could be a hundred dollars for 30 days to 60 grand for 30 days. So, so let's let's you know, kind of start at the beginning. And often what I'll do is I'll I'll tend I'll tend to spend 15, 20 minutes with folks asking them uh some very specific, open-ended questions to just get an idea of what's happening. Um, you know, give me some examples of what's going on in their life or the loved one. Uh, how long has it been a problem? Uh, what have they tried? You know, have they gone to treatment before? Um, did it work and to what degree? And when I say did it work, I'm not trying to be cheeky. It's just, you know, did someone go to treatment and have a period of of mental health symptom reduction and stability or uh abstinence or reduced use, you know, was there some sort of stability um or or not? And for how long? Um, and then I'll ask them uh, you know, sometimes depending on the the type of person I'm talking to, I might ask how much do you think that's that that process has cost you, or what do you think the consequences have been for you know going this way or that way or not doing anything or not trying anything? Um, and then I try to ask them, you know, how do you feel about that? Like what's what is your you know, you've you've described me what you're struggling with and what's going on. How do you really feel about it? And often most folks say, you know, I'm really frustrated and upset, or a family member might say, I'm really scared and I don't know what to do.
Speaker 2:And then I'll ask because I keep running up against a wall, right?
Speaker 1:Yeah, right. I've tried everything and nothing's worked. And then I typically ask them, you know, are you willing to to to walk with me um to see what a solution might be? Have you have you kind of given up trying to deal with it on your own and willing to have a conversation? And by this point, they they they they say yes. So then the next thing I asked them, I say, um, you know, hey, a lot of folks want to talk about the time, the energy and the money it's going to take to um support your loved one or or help you through this process. Which one of these do you want to talk about first? Um, and then I just I just start with whichever one they start with. You know, if it's time, you know, I'm referencing how long you might be in treatment, how quickly you can get to treatment. So so I try to give them some time parameters. Um, and then energy, I'm referencing you know how much work it might have to take, a phone call, a flight, a car drive, or uh a letter probation officer. Yep. Um, but then the big one, and sometimes it's first, but sometimes it's last because people get uncomfortable around money, um, depending on how they're raised. Um they they'll say, um, you know, I want to talk about the cost. And then that kind of brings us into what we were just talking about. So so before I even talk about money, I try to do a lot of this information gathering prior to so I can really understand as much as possible kind of where we're at, what what what what has been tried and what hasn't been tried, um so that we can have a a uh broad conversation about the cost. Um so to that point, uh just because you have more money than God doesn't mean you need to spend it all. Right? And just because you have Medicaid doesn't mean that there aren't any options. Right. So if I've done those questions prior to, that prepares me for, you know, if I've never asked, if I don't ask what what have you tried before, I may offer a suggestion that either they've already tried or they just don't have the resources for because they have tried these things and now they they they lack resources. So um I went a very long-winded way to to to get to the question about money and enter.
Speaker 2:I think you're talking about profile, you know, giving, which is why I mean I you may I know that you get this, I certainly do, which is the occasional text message or email message like, hey, I got a I got a friend or I got a somebody that needs X. Have you got a couple of programs? It's like, yeah, well, no, actually. Can you make it a million of them? Let's what's their so what is their gender? First of all, let's let's let's maybe start with that. How do they identify right? How do they identify what's the issue, etc. etc. And like it, you know, it's not enough, it's not enough to to try and address somebody's questions or their needs with just one, you know, channel, money, program, etc. You've got to you've got to have a profile so you know where you can land and what questions to start asking. If they were on Medicaid, it's a whole different set of questions, different from a person who's using private insurance or is ready to private pay all the way through to the hilt if they need to. So those are very different profiles of people.
Speaker 1:And if you're on probation and can't leave the state of North Carolina, then it really doesn't matter what exists outside of the state of North Carolina, you know.
Speaker 2:You can. They don't like it. Right. But it's gonna take you a lawyer to get there, but sometimes you can uh leave the state of North Carolina, usually you cannot, or they don't they don't want you to for sure. Right. Um I've had a couple where I've been able to pull it off, but yeah, absolutely.
Speaker 1:It's uh it all depends on that probation officer and how much legwork they want to do, uh at least in my experience. So so to that point, right? So so if we if we just answer the the question or just answer the text, we could really uh do some harm. We could we can make a recommendation with very little information, um and and it could really be a bad fit, right? Um same thing with Lakeview, you know. So if if somebody calls me and we're looking at Lakeview as a as a potential option, you know, ultimately, um, and I'm not just saying this because it's the the you know the correct thing to say. I really want to bring in a patient that we're a good fit for, and I want that patient to also be a good fit for us. Um, you know, it it doesn't I've been doing this long enough, and I've seen enough round pegs shoved in square holes um that to to know that it rarely uh works out. Um and and there's a lot of programs that um and this isn't a judgment thing, it's just kind of the the way the system works, is um, you know, folks get um not enough questions are asked, and and somebody comes into treatment and to a program that's not a good fit for them, um, or they're moving too quickly, or they're bound by some insurance components and and their their options become really narrow really quick because they we didn't do the legwork, we didn't ask the questions, we didn't we didn't trust the process that if we're not the right fit, maybe there's a better option.
Speaker 2:Let me um, if I may, so these are some of the barriers that I run into. And I would love for you to elaborate my list a little bit if you can. You and you probably can, but so it's like, all right, let's let's start this insurance, let's start asking the insurance question and let's start figuring out what it is. It's like, okay, right, what state are you in? What policy is it?
Speaker 1:Yeah.
Speaker 2:Is it, you know, who does it and who does the policy belong to? Maybe it's a blue cross blue shield, but it belongs to some other managing entity, or maybe the maybe it's an employer that's managing it itself.
Speaker 1:You know, there are a lot of behavior health benefits are carved out to someone else.
Speaker 2:Correct, right? They're being offshooted. Does it have does it have do you have out-of-network benefits? A lot of the private pay entities or or you know, high-quality facilities are out of network, not all of them, but a lot of them are. So you need an out-of-network benefit. The other barrier I see is people don't have a residential care benefit. They they they will pay for PHP and IOP, partial hospitalization or intensive outpatient, for those who don't know what those are, but they won't pay for they won't pay for residential or they'll only pay for residential. Let's say, you know, to you and me, when I hear residential, I think 60 to 90 days. Yeah, when you're dealing with an insurance company at 12 days of coverage, they're gonna start calling, hey, are they better yet? Right. Yeah. Um, and then you know, the rest of the barriers are, you know, what's the out of pocket gonna be? What's the percentage of coverage for a mental health or addictions care? Um, if it's a primary mental health um kind of issue, and the person doesn't have any co-occurring substance issues. One late um now, correct me if I'm wrong, like if you are you guys dual license now. Is that true? Did I understand that to be true?
Speaker 1:Yes, but we have a a special waiver in the state of Florida to provide uh primary disordered eating treatment uh in our women's program. So so we have a licensed mental health license specifically for eating disorders and that and that women's program that will be coming online um in spring of 2020 2023. But we that's good for me. We're licensed primary addiction, but we we serve mental health co-occurring, but but that's uh even that's uh difficult one to explain, too.
Speaker 2:Right. So here we're we're and I there's a therapeutic side of this, and I would say that an addictions issue at the level of at the level that needs residential treatment is a mental health issue. I would argue that insurance companies do not feel this way. Um, two different versions. You've got primary mental health diagnoses and you've got primary substance use diagnoses, and you can have those co-occurring, but they look at them as independent. So if you're gonna go to someplace that's an addictions treatment place and you don't have a primary primary addictions diagnosis or issue, they're not there, they even if they're appropriate to treat you, your insurance company's not gonna pay for it because you don't bear the diagnosis that is appropriate for treatment at that particular facility and or your coverage. And there are some plans that don't carry a primary mental health treatment um benefit, they will carry an addictions benefit or a substance use benefit, but not a primary mental health. So one thing that we're seeing in the field is that we're seeing facilities dual licensed, so that by the term that person finishes, quote unquote, right, their residential treatment for substance use, they can now begin residential treatment for primary mental health, and they can carry that out in order to get more days out of their coverage. And then you start, and then you run into the rest of the stuff, which is um, you know, you've got you're in network blue cross blue shield, but it's blue cross blue shield of Florida and not a California, and but not California or Tennessee or North Carolina or whatever it is, or it's managed by this entity, and that entity doesn't recognize this list of providers that's in that work, or all these kind of really drilled down specific aspects of of coverage, which is why you have to say, well, it all depends. Um, and then finally what rate they're gonna actually reimburse you at for this level of care.
Speaker 1:I think you hit it all, man. Did I get it? I mean, I mean, you you you nailed it. It's a in in I mean you listed, I mean, I lost count, 20 barriers all related to just insurance. Gone are the days. I mean, I still get a occasional phone call where the person on the other alliance, uh, I'm from North Carolina, so I can say this. So but typically it's a you know uh a southern fella that says, I got good insurance. Well, that doesn't really that doesn't really exist anymore.
Speaker 2:Uh the accent was good too. You nailed it.
Speaker 1:Hey, that's that's my hometown. Uh so um, but you're right. And in in whenever I describe navigating, and and we'll stick to insurance, but then just to broaden it a second and going back to options. So so if you have zero dollars, zero, zero zero insurance, right? There are resources for uninsured folks. And North Carolina is one of the unique states that that actually has options for that. And there's grant programs and work programs, and there's there's options there. So if you have nothing, you do have options. No options. And then there's a category where if you have Medicaid, uh, North Carolina Medicaid, there's options there. Uh, just a little caveat there. Medicaid rarely crosses state lines. There are some specialties where you can go across state line to get a specialty thing, but in general, you know, North Carolina Medicaid stays in North Carolina Medicaid. Then there's another call, which is Medicare. We could do a whole podcast just on Medicare. Oh my god. A B C D advantage plans. Uh, just so you know, there's no addiction benefits in advantage plans. Um, Medicare is only accepted for you know for inpatient residential, it can only be accepted in a hospital setting. So there's limitations there.
Speaker 2:And and there are especially Medicare plans out now that are paying for residential care, but you have to apply to be part of them. Ah I have only become recently aware of this because there's a program that's accepting it in North Carolina, another facet of this complicated thing that we're talking about.
Speaker 1:So I've I've learned something today. I haven't heard that one yet. So, but but it's its own little uh vertical or uh column. It's a box, it's another box, right? And then you have commercial insurance with all the bugaboos you mentioned, and then there's the self-pay, and self-pay is sky's the limit. You know, I've I've seen there's technically residential programs in in in North Carolina that cost $2,500 for 28 days. Um and then there's programs and you know, really good programs that are uh you know throughout the country that are 60 grand for for 30 days. So you know, cash pay is a whole nother bucket. So we've we've we've you know, I've I've I'm speaking to a lover, I'm speaking to a person, I've I've walked through these questions, I ask them, you know, time, energy, money, which one are you gonna talk about? And they say money. And then they say, I'll I'll say, well, tell me a little bit about your resources. Do you have commercial insurance? And so if they say yes, and they use uh kind of your bigger names that we know in in insurance, so Cigna, Aetna, United Healthcare, uh, Blue Cross Blue Shield, those are the all the main players. There's some smaller players, Friday Health Plans, Med Cost, Health Smart. There's some other things in there, but but the the main ones that you see are those those ones I mentioned first.
Speaker 2:And then there's the level of plan, maybe it's a gold or a silver or a platinum.
Speaker 1:Tier one, tier two, gold, platinum, yeah. Um, or a state. So uh the the case I'm working on today, or person I'm working with today, has Blue Cross Blue Shield of North Carolina state employees plan. Right. That don't mean that it's blue cross blue shield of North Carolina. It's just that's just the manager of it, but the benefits can be completely different than if you bought Blue Cross Blue Shield off of the marketplace. And then you have marketplace plans, and that's a whole another thing. So Lake View Health is in network with Cygna Netnet, but we're not in network with the marketplace plans.
Speaker 2:Well, and I I'll tell you this, this is something I've run into as in a barrier with through all of this, we still have yet to do yet to identify, but marketplace plans are HMOs, and they are they don't carry they don't carry out a network benefits. And if you look at their provider list, uh they are their provider lists are not extensive, and you know, a lot of times they're if it's a you know provider list for the state of North Carolina or South Carolina or Florida or whatever, it's usually limited to that state with some you know occasional at the line crossovers. And so your provider list, or it's a provider that is in your area but has a national presence, like in hospital settings, for example. Sure. Yeah. Um, so you run into this, it's like, I've got a, you know, I've got a client right now, a person's in their 30s, you know, the the person who's in need of care is in their 30s. The parents are like, hey, what do we do? I said, well, it'd be good for him to have insurance. It's like, well, you know, um, maybe we could just jump on and get, you know, marketplace. I said, I ideally, I think that in the long run, yeah, sure, a marketplace plan is gonna do you well because you want him to have health coverage. But if you're doing this in order to specifically help you pay for treatment, mental health or addictions treatment, you're not gonna find a lot of choices that are in network and they they don't have an out-of-network benefit. So if you're going to this facility, it's probably gonna be out of network for you, and you're gonna get zero back on that investment. So please go to a broker and buy yourself a private market plan.
Speaker 1:Yeah. That actually might have been been the case that we both were working on this.
Speaker 2:I think you're right, actually.
Speaker 1:Yeah. You got something with Anthem, Virginia, right?
Speaker 2:Right.
Speaker 1:HMO policy, your only options are in Virginia, but if you're if you're struggling with addiction and your use is predominantly in you know the the place that you live, uh, and then you're you're restricted to the state that you live in, um, it can become a ideal scenario. Yeah. So so what do we what do we do, right? So you just because you got insurance doesn't mean we've got a silver bullet here. Um so you know, uh what I do is well, where we start is so I I I've asked them, do you have commercial insurance? They say yes. They say I have you know one of the one of the ones mentioned or or some other. And I'll say, Great, fantastic. Um, and they'll say, Do you take that? To which point I say, uh typically yes, or uh we have worked with it before. Um, however, uh just because it says XYZ name on on the card doesn't mean that it's a slam dunk. So what we actually like to do um is collect your name, date of birth, your insurance information. And then what we will do is call it a uh insurance verification or a verification of benefits. And so, yeah, VOVD, there you go. And and what that essentially is is one, uh, we're confirming that this plan is even active. And some people don't even know. They're not trying to be deceitful, they just really they they thought they had it.
Speaker 2:They don't realize it lapsed last month.
Speaker 1:Yep. Especially when you're dealing with um, I mean, you work with a lot of young adults, um like the 25 to 30 year range where you're not you're no longer on the parents' insurance, so somebody else hasn't paid premium, yeah, premium. Uh you're supposed to be in charge of the premium, but you've been, you know, experiencing mania for the past four weeks, uh, or you've been a hospital. You've been in a hospital, and so you may not even know where your insurance card is, much less whether or not the premium is paid. So that verification benefit to confirm is the is the benefit plan active? Um uh when does it renew? That's a whole nother, that's another barrier, right? So we're at the end of the year. So most insurance plans restart at the first of the year. So what that means is if I pay my deductible and out-of-pocket max today, December uh 1st, and I'm in treatment 32 days, I'm gonna have to pay my deductible and out-of-pocket max again January 1st.
Speaker 2:January 1. That's right.
Speaker 1:That's crazy.
Speaker 2:And of course, you know, that that because I keep getting reminded by you know various things that December becomes an enrollment period for people. Um, well, uh like September is September's an enrollment period. Sometimes you can qualify for special enrollment if you've lost your insurance and they can get you in on a plan. The other thing I'll throw in there is that occasionally, I know that you guys do this and have before, um, in my experience at least, is negotiate a single case agreement, yes, which is to, you know, even if you say you're not in network with insurance, or the provider is not one that you've worked with in the past, but you can reach out to them and say, Hey, we think we're the right provider, let's let's let's pretend that we're in network with you guys and negotiate a rate around it. And that way that can that can that can get people down the road a little bit. It's a trick, it doesn't always work, but it is something to keep in mind and certainly something to bring up with insurance companies. Um, out, you know, out past all of this that we're talking about, um, you start to finally get to the, you know, you run the verification of benefits for the family, and you finally get to the out-of-pocket piece, which yeah, by the there's probably gonna be some. There are a few cases where people are getting, you know, 100, 80 to 100 coverage. They they exist. Um, but uh otherwise people are coming away with some out of pocket and probably some amount to pay up front. How do you let's say that that's an amount that's gonna be challenging for you to navigate. What resources are you pulling from, Travis, to like help families, you know, handle the handle the the payment amount that they're gonna have to face?
Speaker 1:Yeah, that's a great question. Uh, and I appreciate you asking it. So there's um and there's some rules, right?
Speaker 2:Yeah, totally.
Speaker 1:Uh so um a couple things. All right, so so out of pocket back. So let's say we run your benefits. Uh well, let's walk through two scenarios, right? So let's say we're in network with Todd Weatherly's insurance. Um generally what we are collecting coming through the door, uh and when you when you're in network, it's an actual contract with that insurance company. We have a contract that says we're going to bill X amount of dollars and we're going to get paid X amount of dollars, right? That's the contractual component of it. And we say that we're going to collect the deductible and out-of-pocket max in addition to billing, you know, that that rate, that agreed upon rate. So what we're going to collect is that deductible and out of pocket max. You, as the member or policy holder, your agreement with that insurance company is that you're going to pay that deductible and out-of-pocket max, that that's your portion, right? And that's different depending on what level of insurance you you purchase.
Speaker 2:Now, here is the deductible out-of-max, and there's out-of-pocket max and there's the co-insurance. Yeah.
Speaker 1:Right. There's a coinsurance, right? So when you're in network, there's no flexibility from the facility side of what we can or cannot collect. We're contractually bound by that. Now, we can do a payment plan. So when you talk about resources, uh, we can uh walk through with our billing department what what is um uh what is uh possible for the family to pay. And so we can do a payment plan on those collections, but we are required to collect it right now. Additional resources, whether it's in network or out of network, there are some um nonprofit uh scholarship programs out there. Um big change from time to time. So I don't have an active list of anything, but but there are some programs out there that can help families subsidize. A lot more for adolescent care than adult. Yeah, uh, that's often the case. And then there's some specialty scholarship programs for like specialty populations. So first responders have a lot of support these days, uh, veterans have a lot of support these days. So there's some scholarship funds available to assist that that that person with covering some of those deductible and out-of-pocket costs. Now, we can't, as a provider, it's illegal for us to subsidize that or pay for that or waive that. Um, so we we are contractually bound to collect it uh or attempt to collect it. I mean, you know, if you if you can always not pay me, or you can give me a fake credit card, or you know, uh, but we then have to walk through a collections process and that just gets really sticky. Uh, but we're contractually bound to to uh collect that.
Speaker 2:Clarify this for me real quick, Travis. Um do you now I'm aware that medical expenses you cannot you can't be even if you don't pay, let's say you don't pay your medical bill to the hospital, they can't put that on your credit because you credit can't go on your medical expenses. That include the treatment at the addictions treatment industry as well, mental health and addictions treatment industry.
Speaker 1:As far as I'm aware, yes. Okay. Yeah. Yeah, it would just ding your credit. Or no, I mean, uh, it wouldn't ding your credit.
Speaker 2:Um you call a collections agency and you're gonna try to do that, you're gonna try to collect, but yeah, right.
Speaker 1:I mean, I'm not gonna, I can't, you know, we can't track you down and send people after you. Um I mean, and so we're at risk too, right? Um, so that's generally what happens with uh in network. Scenario two. Todd Weatherly has uh an insurance that like ViewHealth isn't in network with. Um and you know, let's say you're on your spouse's policy and it um let's say it it we're gonna do two scenarios on that. So let's say it has out of network benefits and we are out of network. Well, then we have a little bit more flexibility because there's no contract. We don't have a contract with that insurance company. So we can be a little bit more flexible with a payment plan. Now we still are required to collect, um, but we can be uh a little bit more um flexible just on on how much coming through the door and and length of payment plan and that sort of thing because there isn't an official contract. Um so um so that that's an option. Um and every company does it a little bit differently.
Speaker 2:Uh, you know. The one barrier people I see people run into with the insurance companies on that end is okay, they haven't had a network benefit, right? But insurance companies, it's gonna come as a shock to everyone listening, but um, they will try to deny you coverage when you're out of network. Just when you're out of network, they're gonna try to deny you coverage. So if it's out of network, you have to do a little more fighting for it. Um and it's it's a bit more of a battle. There are back to the payments. There are there are companies that have, you know, you can that will loan you money for medical expenses. There's a couple of them out there, and then uh on the other side of that, there are also claims, denials, management companies out there that will help you get more from your insurance company after they've denied your claim or haven't paid you as much as you thought they should. Those companies exist out there as well. I assume your other scenarios, if uh you know they don't have an out-of-network benefit and their leverage decreases rather significantly in that scenario. Right. Yeah. Um not impossible. I mean, it's been done, but it's not it's been done, but it it's it's harder.
Speaker 1:Um and and really quick on the out of network uh process, um often the deductible and out of pocket max is is higher. Typically it's double, but I've seen it be I mean I've seen um unlimited out-of-pocket max, which basically means you can go out of network, but you're essentially a cat pay, right? There's not even not even any point to use your interest because it's you know the the there is no limit to the out-of-pocket max uh payment. So it's it's really um the the terminology is even incorrect, out of pocket max. There is no max. Um and I was gonna go somewhere with that. Oh, so what that what so typically if you're let's say you're in network, we're in network with your insurance and your deductible is $2,500 and your out of pocket max is five grand. That typically is the way, it's not always that way, but it's typically $25, you know, like a uh one number deductible and then double that for out of pocket max. Um and then out of network is typically that out-of-pocket max for deductible, so five thousand dollar deductible to ten thousand dollar out of pocket max. That's generally what you see the trend as, but those aren't fixed numbers. Um so you can come to Lake V Health um out of network for uh you know 10 grand in that scenario, um or you can go in network somewhere for five grand, but it may not check all the boxes you you need or want. Right. Um and we view the out-of-pocket max as your out-of-pocket max. Like once like that term is exactly what it means. Uh, this is your maximum out of pocket for you. Um, anything above and beyond that is between us and the insurance company.
Speaker 2:A four-year length of stay, unless, like you say, you're sitting in December.
Speaker 1:Yes, and you've correct and you've got restart.
Speaker 2:And your your clock resets when you hit January 1. The other one.
Speaker 1:Well, like my former employer where the benefits reset in uh first of September. So it was fiscal year, like you know, so then you're that's a those do happen occasionally, but but most of them are are annual. Um and and uh the other thing I was gonna add on that was um out of pocket max. Oh, there are companies um that do what's called balance billing. And so if the program you know is 60 grand and your insurance covered 30, you're on the hook for the additional 30. Um, we don't do that, but but some companies do what's called a balance billing. Um, so they're covering all their costs.
Speaker 2:Our program is 90 days. This is what we've checked your benefits for being. Right. This is gonna be the same.
Speaker 1:The benefits will cover this, the remaining balance is this.
Speaker 2:And we're gonna need that. Yeah, there's a there's a program out in Texas that does it that way, though you can ask to pay uh, you know, the uh the whole amount, but let me pay it in three chunks or whatever, you know.
Speaker 1:Yeah, the only thing happened when when when my wife and I had our our child. I mean, that was that was essentially how it happened for us. This is this is the total cost, this is what we project your insurance covering. Um uh all also, by the way, your deductible restarts in the middle of this pregnancy. Um and they also but but what they did because you have nine months, you don't have this in the eviction world, right? Uh you can start paying towards that uh throughout that nine month period or eight months or how however long it takes for you to figure out, right? So they can they can do a payment plan, but that's essentially a balance bill.
Speaker 2:Yeah, usually you usually the company, the provider that is the treatment company is the one that's gonna, if you're gonna pay balances, then they're gonna do that for you, not your insurance company in that scenario. The only scenario I can think of that we haven't covered yet before we run out of time here is the is uh which we run into a lot with adolescent and young adult treatment and wilderness. Wilderness in the state of North Carolina and in most places with a couple of exceptions, is the wilderness program can't be deemed residential, so they can't license themselves residential because you don't stay anywhere. Um you're always roaming about. There's no place to license. Therefore, they have to, you know, sometimes they'll have PHP offices and they can do it that way. But what they're giving you ultimately is they're not they're not billing your insurance for you. They're sending you a super bill. So for every therapy session and group and whatever else, all therapeutic care you've received, they send you the super bill that shows you all of those and the billing codes and and how much. But you know, a lot of times for a 16, 16 to $20,000 program, you're coming away with about $8,000 worth of billable fees, and you're gonna get about half that back. And it's you know, and it ain't great. Um, but that that's the that's the the only scenario I can think of that we haven't covered yet. So if a if an insurance company is not, or excuse me, if a provider's not gonna, you know, like, well, we don't bill insurance and everything else, and they didn't they don't say that they provide a super bill, you can ask for one. So that's something you should do. Correct.
Speaker 1:Right. Um that's always really helpful. And when I've seen people do it, it's it's a pretty laborious process, but it can be done. Uh and then uh the out of you know, no out of network benefits that kind of falls back into your HMOs, your EPOs, or the behavioral health benefits are carved out to a really narrow network. And then you're basically forced into your only option if you're gonna use your insurance is whatever that insurance company says your network is. Um and sometimes that it can there can be some options in there, but often uh they don't check all the boxes you're looking for. Um or you know, you're in school in Oklahoma and your parents got you, you know, the school plan, right? Virginia, uh, and your only options, you know, in that EPO HMO policy is back in Virginia. Well, if you're in Oklahoma in the hospital, like I mean, come on, let's how do we get there from here?
Speaker 2:So Yeah, it's a it's a complicated system. I think my advice to people is find somebody who knows what they're talking about. Yeah.
Speaker 1:And some days uh that may not be me, you know, when when insurance stuff changes, um, I mean, I'm learning every single day how to navigate this. And what I do right now for Lakeview is I specifically work with our corporate relationships um and working on the employer-employee side to help the employee understand their their benefits, um, help the employer um help uh employees navigate those benefits um and get the care they need all the way through, not just a portion of it.
Speaker 2:Right.
Speaker 1:Right. And get well and then come back to to work.
Speaker 2:Uh yeah. I you know, I think that the thing at the end of all that is, you know, as people look at this, and you've seen people that'll they'll I mean they're gonna refinance the house and they're gonna do all these things and end up with a lot of expense, and maybe that's worth it. I mean, it's possible that it is. Uh, but I I would, you know, where you started with this was building a profile for a person and understanding where they're coming from, including the willingness of the person to engage. Have they been in treatment before and was it successful? How do you feel about it? Like, how are these things? They're important because, you know, I tell people find the right thing to do and do it for long enough. You know, just like any form of care, you need to do it for the prescribed amount of time. That amount of time is not dictated by an insurance coverage, it's dictated by the providers that give it. So you're there to do for a result, not for a period of time. Um and if if a person's unwilling to commit to that, if they're unwilling to do all the pieces about it, I I would I would stage my level of financial engagement per the scenario that you're faced with and take it a step at a time um and get people involved who know what they're talking about. So you go in armed with good advice and good information. I mean, that's just I'd say that about anything, but definitely about this.
Speaker 1:Absolutely. And and we didn't even touch on it, we can do a part two criteria. You know, uh there's a whole level of criteria that that is involved in this insurance piece.
Speaker 2:When we part two this, we're gonna do admissions criteria for for for residential treatment. That that'll be our that'll be our next one. We we've navigated the insurance and now we're gonna go for the clinical side of this equation. Um, Travis, thank you so much for joining me. I'm I'm really happy I had you here for this topic. It's good to have somebody backing me up with good knowledge. I always learn something when you're here. This is Ben Head Inside Mental Health with Mr. Travis Herman. I've leathered with your host. Thanks for being with us, folks. We'll see you next time.