ASAM provides resources for its members to navigate third-party payment

Reimbursement for Medications for Addiction Treatment Toolkit

ASAM has developed a toolkit to guide addiction medicine providers on how to bill third-party payers for treating patients with substance use disorder (SUD) with medications for addiction treatment (MAT). Due to the complexity and heterogeneity of the health insurance system in the United States, this toolkit will focus on billing and payment policies established by Medicare and Medicaid, the nation’s largest payer of SUD treatment and recovery services.

 

This toolkit includes the following resources: 1) An overview info of MAT billing; 2) Information about state Medicaid payment policies; 3) Information about alternative payment models; and 4) Strategies to address reimbursement issues. 

Third Party Payment Policy Statement

Patients who suffer from chronic medical conditions like addiction can achieve remission and sustain recovery when high quality, coordinated whole-person care is readily available and affordable. Insurance coverage for health care can make access more attainable by making it more affordable.

This policy statement addresses some of the key issues facing clinicians and third-party payers as they work together for the benefit of patients to solve the real-world practical problems of access to care, reimbursement for professional services, insurance benefit design, and health plan clinician network adequacy.

ASAM Letter for Non-Psychiatrist Addiction Specialists

Given the wide treatment gap among patients needing treatment and the doctors available to treat them, ASAM recommends that payers should add non-psychiatrist addiction specialist physicians certified by the ABPM, ABAM, ASAM, and AOA and non-psychiatrist physicians who have completed an accredited residency/fellowship in addiction medicine to their in-network provider panels to treat patients diagnosed with a substance use disorder (SUD). ASAM is happy to provide this letter as a resource for non-psychiatrist addiction specialists experiencing exclusion from provider panels in public and/or private payers networks. Please contact ASAM Staff at advocacy@asam.org for assistance using this form letter.

 

Read the letter here

Utilization Management

Utilization management is a set of techniques used by payers on behalf of purchasers of healthcare benefits to manage healthcare costs, ensure services align with payers’ medical necessity criteria, and reduce or eliminate care that is wasteful, inefficient, or unnecessary. 

The two most common forms of utilization management are prior authorization and fail-first policies. They can be used (1) to direct prescribers to less expensive branded or generic medications, (2) to help ensure adherence to standards of care, (3) to identify dangerous medication interactions that prescribers may miss, particularly in cases where patients are receiving medications from multiple providers, and (4) control costs.

Utilization Management for Medications for Addiction Treatment Toolkit

ASAM has developed a toolkit to educate clinicians on how to navigate the various forms of utilization management that payers apply to medications for addiction treatment. The toolkit provides background information on the utilization management process, as well as analysis of the advantages and disadvantages of various prior authorization methods. Funding for this initiative was made possible (in part) by grant no. 1H79TI081968 from SAMHSA through PCSS.

Report a Payer Issue to ASAM

Use this form to report issues with payers related to utilization management, parity or other areas.

AMA Prior Authorization Toolkit 

These resources from the AMA include tips to make the prior authorization process easier for physicians and staff.