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News & Views - Dec, 1992 Issue 

Working With Insurance
By Larry Stednitz, Ph.D.

I have followed, with great interest, the articles in Lon's newsletter related to insurance coverage for residential treatment and special purpose schools. Over the years, I have had the opportunity to work extensively with an entire range of insurance carriers and managed health care companies. Through the Western Youth Network, our effort was to obtain deserved benefits for families and their children. Because the Network is supported by Capistrano by the Sea Hospital, all of the latest technology, and clinical expertise was, and is, available for assisting families in obtaining coverage for "out of policy" and "in policy" coverage. We have seen major changes in the families abilities to access insurance for non-Joint Commissioned Accredited programs as well as changes in the coverage for hospital organizations. A few of these changes have been:

  1. Reduction in hospital stays from roughly six months to 20 days.
  2. Reduction of accredited residential treatment days.
  3. from one to two years down to three to six months.
  4. A greater willingness for insurance carriers to fund wilderness programs.
  5. Increased payment for low cost special purpose programs that resemble a medical model.
  6. A reluctance of approval for coverage for any program that exceeds six to 12 months of care.
  7. Increase in coverage for new products like in-home treatment programs.
  8. The continued growth of managed care companies.

Any successes with insurance coverage will necessarily come through a thorough understanding of insurance and managed care companies, an understanding of medical and clinical necessity, and a knowledge of varying continuums of care. All require careful clinical and medically approved monitoring and supervision. There will be continued opportunities for providers who work very hard at learning the game and who continue to develop good clinical practices based on research. Our experience has been that if one is to be successful in these endeavors, a full commitment has to be made by any organization expecting to access insurance funds. This typically means employing one or more persons to handle all insurance or managed care work. Consultation is also frequently required as well as the development of extensive documentation systems. Many have benefited from expert consultation in this area to determine their organizations willingness for entry into this complicated arena.

Copyright 1992, Woodbury Reports, Inc. (This article may be reproduced without prior approval if the copyright notice and proper publication and author attribution accompanies the copy.)

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