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How-To Guide: How to Understand Insurance and Billing Issues
BupPractice.comBuprenorphine Training and Practice Tools (DATA 2000 Training at BupPractice.com)© Clinical Tools, Inc. This site is for educational purposes only and medical decisions should not be based solely onits content. This site, its authors, and its consultants do not assume liability for errors oromissions. All content is copyrighted to Clinical Tools, Inc.
How-To Guide: How to Understand Insurance and Billing Issues
How-To Guide: How to Understand Insurance and Billing Issues
Tips and advice about:
Commonly used CPT codes for buprenorphine treatmentSetting up a cash-only buprenorphine treatment programOverviews of Medicaid, Medicare, and private insurance coverage forbuprenorphine treatmentCost of buprenorphine treatment to patients
Plus resources on each page with additional tips and tools!
Written by Clinical Tools, Inc.
Reviewed by experts in buprenorphine treatment
Publication date February 9, 2009. Updated December2013.
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Commonly Used CPT Codes - Primary Care
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How-To Guide: How to Understand Insurance and Billing Issues
Commonly Used CPT Codes - Primary Care
Although there are few specific codes for billing for buprenorphine treatment (nor for all ofaddiction medicine), most private health insurance companies are now covering the cost oftreatment. PCPs have been successfully using standard evaluation and management outpatientbilling codes for both the induction and maintenance stages of treatment.
Coding is either based on complexity of service or time, with four contributing components:
historyphysical examcomplexity of decision-makingcontributing factors (eg: time)
In the event of an audit, the documentation for a single visit must stand alone, unless anotherrecord is specifically referenced.
The most commonly used CPT codes by Primary Care Physicians are as follows: Type of Visit CodeAssessment Visit:Comprehensive evaluation of new patient orestablished patient for suitableness forbuprenorphine treatment
New Patient: 99205
Established Patient: 99215
Induction Visits:Any of the new patient evaluation andmanagement (E/M) codes might be used formaintenance visits. Codes listed are in order ofincreasing length of time with patient and/orseverity of the problems.
Psychiatric outpatient counseling code doesnot specify minutes.
Prolonged visit codes (99354, 99355) mayalso be added onto E/M codes for servicesthat extend beyond the typical service time,with or without face-to-face patient contact.Time spent need not be continuous.
New Patient E/M: 99201-05
Established Patient E/M: 99211-15
Patient Consult: 99241-45
Psychiatric Outpatient Counseling: 99251-55
Add-on Codes:30-60 minutes: 99354; 60+ minutes: 99355
Maintenance Visits:Any of these established patient E/M codesmight be used for maintenance visits.
Counseling codes are commonly used to billfor maintenance visits, since since counselingand coordinating service with addictionspecialists comprise the majority of these
Established Patient: 99211-15
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How-To Guide: How to Understand Insurance and Billing Issues
Type of Visit Codefollow-up visits.
See the following page on counseling for moredetailed information on how to bill for thesevisits.
The current ICD-10 code for opioid dependence is F11. The new code must be used by October2015. The ICD-9 Code for opioid dependence was 304.0x. For the (x) use theseclassifications: 0=unspecified, 1=continuous, 2=episodic, 3=in remission.
Some private health insurers are developing standard billing codes for buprenorphine treatmentservices. For instance, Cigna tells clinicians to use the HCPCS code for "unspecified mentalhealth care" for buprenorphine-related visits. The code is H0033 - Oral MedicationAdministration, Direct Observation. Cigna allows for approximately $300 reimbursement for theinduction visit.
Related Resources: NAABT Coding GridDescription: Displays the appropriate CPT and HCPCS billing codes for the different phases ofbuprenorphine treatment.Source: The National Alliance of Advocates for Buprenorphine Treatment (NAABT)field_vote:
Tags: Insurance and billing issuesBillingInsuranceMedicareMedicaidCPTHCPCSsPaymentMisc. informational materialsJust became waiveredSetting up a practiceExperienced prescriber
PCSS-MAT Guidance: Billing for OBOTDescription: This clinical guidance from the PCSS-MAT provides a list of commonly used CPT
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How-To Guide: How to Understand Insurance and Billing Issues
codes for buprenorphine induction and maintenance. Information is includes for bothpsychiatrists and non-psychiatrist physicians. Source: PCSS-MATfield_vote:
Tags: Insurance and billing issuesBillingCPTDrug codesHCPCSs
Improving Access to BuprenorphineDescription: This is an article written by CIGNA Behavioral Health's (CBH) Senior MedicalDirector. It describes how CIGNA addressed reimbursement, a major barrier to physicianprescription of buprenorphine, by identifying an HCPCS code (H0033) that physicians can useto bill for the services provided during buprenorphine induction visits.Source: Nemecek, Doug. Behavioral Healthcare: November 2007. field_vote:
Tags: Logistics of buprenorphine treatmentInsurance and billing issuesBillingCPTHCPCSsPaymentCost of treatmentJournal articleJust became waiveredSetting up a practiceExperienced prescriber
Commonly Used CPT Codes – Primary Care (PDF)Description: PDF of Commonly Used CPT Codes in Primary CareSource: Clinical Tools, Inc.field_vote:
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How-To Guide: How to Understand Insurance and Billing Issues
Tags: Buprenorphine treatment for heroin addictionGetting a waiver/setting up your practiceScreening and diagnosisInduction and dosingLogistics of buprenorphine treatmentInsurance and billing issuesBillingCPTDrug codesHCPCSsInductionPrintable form/checklistExperienced prescriberJust became waiveredSetting up a practice
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Commonly Used CPT Codes for Counseling - Primary Care
Commonly Used CPT Codes for Counseling - Primary Care
Counseling and coordinating service with addiction specialists will be a large portion ofmaintenance visits. PCPs can provide and bill for counseling without conducting a review ofsystems, and should use Counseling codes in place of E/M codes (99211-15). Documentationfor a counseling visit should include:
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How-To Guide: How to Understand Insurance and Billing Issues
Total visit timeTime spent counseling or coordinating care (must be face-to-face)The nature/content of the counseling
The determining factor for when PCPs can use counseling time rather than complexity in a visitis that counseling or coordination of care must take up more than 50% of of the total visit time.Coding is then based on the total visit time, not just the time spent counseling or coordinatingcare. A statement such as the following serves as documentation of time spent:
"A total of ___ minutes of a _____ minute visit was spent counseling the patient about _____. "Level New Patient Counseling
1 10-19 minutes: 992015-9 minutes: 992112 20-29 minutes: 9920210-14 minutes: 992123 30-44 minutes: 9920315-24 minutes: 992134 45-59 minutes: 9920425-39 minutes: 992145 60+ minutes: 9920540+ minutes: 99215
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Commonly Used CPT Codes for Buprenorphine Treatment -Psychiatrists
Commonly Used CPT Codes for Buprenorphine Treatment -Psychiatrists
For psychiatrists, CPT codes for buprenorphine treatment are time-based. As of January 1,2013, several code changes and adaptations were made:
The time for each psychotherapy code is now described as being as time spent with the
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How-To Guide: How to Understand Insurance and Billing Issues
patient and/or family member, whereas previously it was only measured by time spentface-to-face with a patient.There are no longer separate codes for interactive psychotherapy. Instead there is anadd-on code for interactive complexity, which may be used when the patient encounteris made more complex by the need to involve people other than the patient (90785).There is no distinction made by setting, psychotherapy codes are now applied to allsettings.A code was created for "Psychotherapy for crisis" (CPT code: 90839, +90840), effectiveJanuary 1, 2013.
Please refer to the table below for current CPT codes for the most common psychiatric services.
The most commonly used CPT codes by Psychiatrists are as follows:Type of Visit Service Code Report with interactivity
complexityAssessment Visit:Psychiatric diagnosticinterview exam. Includeshistory, mental status,and dispositionassessments, and mayalso include labs.
Diagnostic evaluation (no medical) 90791 When appropriate
Diagnostic evaluation with medical 90792
Consultation:Used for induction and/orwith an establishedpatient.
- 99251-55 -
Maintenance Visits:For use in all settingswith patient or family(with no medicalevaluation andmanagement)
Psychotherapy
30 (16-37*) min 90832 When appropriate
45 (38-52*) min 90834
60 (53+*) min 90837
Maintenance Visits:For use in all settingswith patient or family(with medical evaluationand management)
E/M pluspsychotherapy (E/M code- s
30 (16-37*) min +90833 When appropriate
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How-To Guide: How to Understand Insurance and Billing Issues
Type of Visit Service Code Report with interactivitycomplexity
elect usingkey components,not time) and oneof these add-ons:
45 (38-52*) min +90836
60 (53+*) min +90838
Group Therapy:Includes outpatientbuprenorphine servicesprovided within anIntensive OutpatientServices program. (codefor group psychotherapyremains the same, butnow includes interactivegroup psychotherapy aswell)
Group psychotherapy 90853 No
*Per CPT Time Rule
The Group Therapy code is an appropriate code to use when buprenorphine treatment isprovided in an Intensive Outpatient Services program.
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How-To Guide: How to Understand Insurance and Billing Issues
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Overview of Medicaid Coverage
Overview of Medicaid Coverage
Because Medicaid provides substance abuse treatment as a state option, Medicaid coveragefor buprenorphine treatment varies significantly by state. Some states reimburse Medicaidpatients for buprenorphine treatment, and others do not, even when it is listed on the formulary.For example, in New Jersey, the Suboxone® tablet itself was covered by Medicaid, but theoffice-based treatment visits were not (Colameco et al, 2005). Check with your state for thecurrent status on reimbursement for buprenorphine.
Medicaid coverage of buprenorphine depends on:
Prior authorization and medical necessityIf your state's Medicaid plan is offered through a managed care or HMO programIf buprenorphine is on your state's formulary list, check online or call your state'sMedicaid office to determine what coverage is available for buprenorphine treatment.
Medicaid Screening and Brief Intervention Codes
New Screening and Brief Intervention (SBI) codes are currently in place in 9 states. Thesecodes, H0049 - Alcohol and Drug Screening, and H0050 - Brief Intervention, enable physiciansto be reimbursed for screening Medicaid-eligible patients for substance abuse.
The states with the codes in place thus far are: Iowa, Maryland, Minnesota, Montana,Oklahoma, Oregon, Tennessee, Virginia, and Washington. Wisconsin provides SBI as part of apackage for pregnant women.
Note for Medicaid licensed providers who live in states where Medicaid pays for buprenorphinetreatment: charging cash for buprenorphine treatment is illegal and state attorney generals havebeen investigating such practices.
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How-To Guide: How to Understand Insurance and Billing Issues
Related Resources: TIP 45. Detoxification and Substance Abuse Treatment. Chapter 6:Financing and Organizational IssuesDescription: This chapter of the TIP 45 discusses funding, resources, organization and patientcontracts in substance abuse treatment.Source: Substance Abuse and Mental Health Services Administration (SAMHSA)field_vote:
Tags: Logistics of buprenorphine treatmentBillingInsuranceMedicareMedicaidContractJust became waiveredSetting up a practice
Evaluation of the Buprenorphine Waiver Program: Reimbursement and Availability TrackingStudyDescription: This study examines decision-making in the buprenorphine treatment distributionand payment systems. The study is based on interviews with health care leaders involved in thedistribution and adoption of buprenorphine.Source: The Center for Substance Abuse Treatment (CSAT)field_vote:
Tags: Getting a waiver/setting up your practiceInsurance and billing issuesCost of treatmentInsuranceMedicaidMedicarePaymentTrainingWaiverResearch report
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How-To Guide: How to Understand Insurance and Billing Issues
Experienced prescriberJust became waiveredNeed to refer
HBO Addiction SpecialDescription: This is the web format of a special addiction program by HBO. The materialcovers issues such as who pays for addiction treatment, and drug treatment for adolescents.Source: Home Box Office, Inc., 2007field_vote:
Tags: General information - opioid addictionGeneral information - buprenorphineInsurance and billing issuesDependenceHeroinPainDetoxificationSuboxonePaymentAddictionCost of treatmentOxycodoneDiscontinuationMisc. informational materialsJust became waiveredSetting up a practiceExperienced prescriberNeed to referBecoming waivered
Links to State Health Department WebsitesDescription: List of contact information and websites for all of the state health departments.Source: Centers for Disease Control and Preventionfield_vote:
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How-To Guide: How to Understand Insurance and Billing Issues
Tags: Insurance and billing issuesBillingInsuranceMedicareMedicaidMisc. informational materialsJust became waiveredSetting up a practiceExperienced prescriberNeed to refer
Opportunities To Use Medicaid in Support of Rural Health ServicesDescription: This PDF offers information on how rural health programs can receive fundingfrom Medicaid for certain services and treatments in order to increase patient access to healthcare.Source: U.S. Department of Health and Human Servicesfield_vote:
Tags: Logistics of buprenorphine treatmentInsurance and billing issuesAddictionMedicaidRuralMisc. informational materialsExperienced prescriberNeed to referSetting up a practice
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How-To Guide: How to Understand Insurance and Billing Issues
Setting Up a Cash-Only Buprenorphine Treatment Program
Setting Up a Cash-Only Buprenorphine Treatment Program
Some providers run a cash-only buprenorphine treatmentpractice in which they set their own fees and costs for treatment. Cash-only-service treatmentproviders should have a clear policy and cost sheet regarding initial and ongoing expenses fortreatment. This should include costs for assessment, induction, and maintenance visits. Youshould also take into account the various costs of providing services to your patients, which mayinclude:
Staff time spent with patientsAdministrative time (i.e. filling out paperwork, answering phone calls)Capital and operating expenses
To get a better idea of reasonable rates to charge for buprenorphine treatment, you may want toconsult with a more experienced provider in your local area. You can contact otherbuprenorphine providers via the PCSS or NAABT websites or SAMHSA waived physicianwebboard.
You need to also be aware of billing fraud. If you have a contract with a health insurancecompany then the contract may prohibit you from accepting cash for covered services, unlessspecific waiver of covered benefits forms are filled out by the patient prior to the delivery ofservices. Accepting cash payment without specific authorization by insurer may be consideredbilling fraud.
Related Resources: Physician Clinical Support System - Buprenorphine (PCSS-MAT)
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How-To Guide: How to Understand Insurance and Billing Issues
Description: This website is designed to support physicians who prescribe buprenorphine bylinking them up with a national network of trained physician mentors.Source: Physician Clinical Support System (PCSS)field_vote:
Tags: Insurance and billing issuesInsuranceMisc. informational materialsExperienced prescriberJust became waiveredSetting up a practice
TIP 45. Detoxification and Substance Abuse Treatment. Chapter 6: Financing andOrganizational IssuesDescription: This chapter of the TIP 45 discusses funding, resources, organization and patientcontracts in substance abuse treatment.Source: Substance Abuse and Mental Health Services Administration (SAMHSA)field_vote:
Tags: Logistics of buprenorphine treatmentBillingInsuranceMedicareMedicaidContractJust became waiveredSetting up a practice
‹ Previous
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How-To Guide: How to Understand Insurance and Billing Issues
Overview of Medicare Coverage
Overview of Medicare Coverage
Buprenorphine treatment costs are typically not covered byMedicare unless the treatment is provided in an inpatient or outpatient treatment center. It mayalso be covered in some instances, such as during detoxification or early stage stabilization.However, the Medicare benefit does not usually cover typical office-based buprenorphineinduction or maintenance treatment visits.
In some instances, Medicare Part D may cover the cost of the buprenorphine tabletsthemselves. Only some Medicare providers will reimburse (including Healthnet Orange,Silverscript, and Wellcare) and prior authorization is usually required.
Learn more about Medicare coverage for buprenorphine treatment by searching the onlineFormulary Finder for Prescription Drug Plans and Advantage Prescription Drug Plans. Note:search under "Suboxone®" in these guides.
Related Resources: American Psychiatric Association Practice Guidelines for theTreatment of Patients with Substance Use DisordersDescription: This website offers comprehensive guidelines for treating patients who havesubstance use disorders.Source: American Psychiatric Association (APA), 2006field_vote:
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How-To Guide: How to Understand Insurance and Billing Issues
Tags: General information - opioid addictionScreening and diagnosisSpecial populationsInsurance and billing issuesAddictionAssessmentComorbiditiesPharmacologyPregnantWithdrawalExperienced prescriberJust became waivered
NAABT Coding GridDescription: Displays the appropriate CPT and HCPCS billing codes for the different phases ofbuprenorphine treatment.Source: The National Alliance of Advocates for Buprenorphine Treatment (NAABT)field_vote:
Tags: Insurance and billing issuesBillingInsuranceMedicareMedicaidCPTHCPCSsPaymentMisc. informational materialsJust became waiveredSetting up a practiceExperienced prescriber
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How-To Guide: How to Understand Insurance and Billing Issues
Formulary Finder for Prescription Drug PlansDescription: This is a database that allows users to search Medicare Prescription Coverageand Medicare Advantage Prescription Drug Plans by State.Source: Department of Health and Human Services field_vote:
Tags: Insurance and billing issuesBillingCPTInsuranceMedicaidMedicareMisc. informational materialsExperienced prescriberJust became waiveredSetting up a practice
The Medicare Coverage DatabaseDescription: This database allows physicians to search for local Medicare policies and relevantarticles. Source: US Department of Health and Human Servicesfield_vote:
Tags: Insurance and billing issuesBillingInsuranceMedicareMisc. informational materialsExperienced prescriberJust became waiveredSetting up a practice
HBO Addiction SpecialDescription: This is the web format of a special addiction program by HBO. The materialcovers issues such as who pays for addiction treatment, and drug treatment for adolescents.
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How-To Guide: How to Understand Insurance and Billing Issues
Source: Home Box Office, Inc., 2007field_vote:
Tags: General information - opioid addictionGeneral information - buprenorphineInsurance and billing issuesDependenceHeroinPainDetoxificationSuboxonePaymentAddictionCost of treatmentOxycodoneDiscontinuationMisc. informational materialsJust became waiveredSetting up a practiceExperienced prescriberNeed to referBecoming waivered
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Overview of Private Insurance Coverage
Overview of Private Insurance Coverage
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How-To Guide: How to Understand Insurance and Billing Issues
Health insurance plans classify buprenorphine as a "niche" medication. This is becauseSuboxone® and buprenorphine monotherapy tablets are prescribed solely for opioiddependence, a diagnosis that companies predict will affect a limited number of their coveredindividuals. However, private insurance companies are increasingly covering the cost of theappointments, and almost all major insurance providers now cover the cost of the prescriptionitself. Companies are also making it easier for physicians to obtain reimbursement forbuprenorphine treatment.
Note that though insurers may cover more costs, there is often a high co-pay amount sincebuprenorphine is typically off-formulary. As such, the cost of co-pay can be exorbitant forpatients and may require planning and foresight regarding dosing and medication refills. Forinstance, federal Blue Cross/Blue Shield co-pays are based on the number of pills prescribed.
Additionally, insurance coverages also vary by region; patients who plan to use insurancecoverage for buprenorphine treatment should contact their provider to see what expenses arecovered. This should be done prior to starting treatment so that there are no unexpectedcharges or fees later on.
Related Resources: NAABT Coding GridDescription: Displays the appropriate CPT and HCPCS billing codes for the different phases ofbuprenorphine treatment.Source: The National Alliance of Advocates for Buprenorphine Treatment (NAABT)field_vote:
Tags: Insurance and billing issuesBillingInsuranceMedicare
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How-To Guide: How to Understand Insurance and Billing Issues
MedicaidCPTHCPCSsPaymentMisc. informational materialsJust became waiveredSetting up a practiceExperienced prescriber
Improving Access to BuprenorphineDescription: This is an article written by CIGNA Behavioral Health's (CBH) Senior MedicalDirector. It describes how CIGNA addressed reimbursement, a major barrier to physicianprescription of buprenorphine, by identifying an HCPCS code (H0033) that physicians can useto bill for the services provided during buprenorphine induction visits.Source: Nemecek, Doug. Behavioral Healthcare: November 2007. field_vote:
Tags: Logistics of buprenorphine treatmentInsurance and billing issuesBillingCPTHCPCSsPaymentCost of treatmentJournal articleJust became waiveredSetting up a practiceExperienced prescriber
Evaluation of the Buprenorphine Waiver Program: Reimbursement and Availability TrackingStudyDescription: This study examines decision-making in the buprenorphine treatment distributionand payment systems. The study is based on interviews with health care leaders involved in thedistribution and adoption of buprenorphine.
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How-To Guide: How to Understand Insurance and Billing Issues
Source: The Center for Substance Abuse Treatment (CSAT)field_vote:
Tags: Getting a waiver/setting up your practiceInsurance and billing issuesCost of treatmentInsuranceMedicaidMedicarePaymentTrainingWaiverResearch reportExperienced prescriberJust became waiveredNeed to refer
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Cost of Buprenorphine Treatment to Patients
Cost of Buprenorphine Treatment to Patients
The cost of buprenorphine can vary depending on the dose. Cost of a dose of buprenorphine isdetermined by:
The pharmaceutical company, brand names and other companies that produce generic
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How-To Guide: How to Understand Insurance and Billing Issues
buprenorphineThe health planRetail pharmacies
Daily doses are normally from 8 mg to 24 mg, and the average retail price for these dosesranges from $4-$19 per day (Sullivan and Fiellin, 2008).
Patients who do not have health insurance can expect to pay around $500 per month forbuprenorphine treatment, which includes the cost of the medication plus the cost of doctor'svisits. These estimates are based on an average dose of 16mg/day ($12 x 30 days = $360) plus$100-$200 fee for office-visits. Of course, these rates will vary based on factors such asgeographic location and proximity of other providers.
A variety of prescription discounts are available for low-income patients.
Needy Meds Free Drug Card Program AAA members can save an average of 20% off the retail price of prescriptions, valid atparticipating pharmacies.
The generic combination buprenorphine/naloxone tablets may reduce the cost to patientssignificantly.
Related Resources: How Patients Pay for BuprenorphineDescription: This pie chart shows the breakdown of how buprenorphine patients paid for theirdoctor's visits. 204 patients in NAABT's physician-patient matching system were surveyed.Source: The National Alliance of Advocates for Buprenorphine Treatment (NAABT)field_vote:
Tags: Insurance and billing issuesBillingPaymentCost of treatmentMisc. informational materialsJust became waiveredSetting up a practiceExperienced prescriber
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How-To Guide: How to Understand Insurance and Billing Issues
Evaluation of the Buprenorphine Waiver Program: Reimbursement and Availability TrackingStudyDescription: This study examines decision-making in the buprenorphine treatment distributionand payment systems. The study is based on interviews with health care leaders involved in thedistribution and adoption of buprenorphine.Source: The Center for Substance Abuse Treatment (CSAT)field_vote:
Tags: Getting a waiver/setting up your practiceInsurance and billing issuesCost of treatmentInsuranceMedicaidMedicarePaymentTrainingWaiverResearch reportExperienced prescriberJust became waiveredNeed to refer
‹ Previous
Summary
Summary
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How-To Guide: How to Understand Insurance and Billing Issues
Most private health insurance companies are now covering the cost of buprenorphinetreatment although there are few specific codes Medicaid provides substance abuse treatment as a state option, therefore Medicaidcoverage for buprenorphine treatment varies significantly by state.The Medicare benefit does not usually cover typical office-based buprenorphineinduction or maintenance treatment visits.Private insurance companies are increasingly covering the cost of the appointments forbuprenorphine treatment, and almost all major insurance providers now cover the cost ofthe prescription itself.The cost of buprenorphine varies with the dose and the retail pharmacy. Cost to thepatient obviously varies with the health plan
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This site is for educational purposes only and medical decisions should not be based solely onits content. This site, its authors, and its consultants do not assume liability for errors oromissions. All content is copyrighted to Clinical Tools, Inc.
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