Payment and Reimbursement

The implementation planning team should identify all diagnostic and treatment codes relevant to MAT across Medicaid, Medicare, managed care organizations, and local commercial payers, such as billing codes from the Current Procedures Terminology (CPT) and International Classification of Diseases, Tenth Revision (ICD-10). The team should identify codes for screening and initial assessment; induction; maintenance visits; associated clinical services (e.g., physical examinations and laboratory tests); and any behavioral health services.

Billing codes to be used may differ based on whether it is a new or established patient and the level of service provided. Different State Medicaid programs may also limit the diagnosis codes for which primary care providers can receive reimbursement.¹ After identifying relevant billing codes, the implementation planning team should train staff on how to use them.

Public and private health plans may have different requirements about who is eligible to provide billable services. There may be limitations on the types of providers who can bill for behavioral health services.¹ For example, for the Nurse Care Manager Model to be feasible and successful, payers must provide reimbursement for nursing visits. Practices should check who is considered “qualified providers” to deliver services across each payer. Depending on the health plan, payment for services and medications for MAT may be delivered through bundled payment or case rates or fee for service.

Patients being treated for opioid use disorder in primary care are often receiving care for a chronic medical condition from the practice or organization. Billing for services in integrated care settings may be further complicated by silos between reimbursement for behavioral health and medical services. Some States may prohibit providers from billing both medical and behavioral health services on the same day.¹ It is commonly misunderstood that these restrictions stem from a Federal policy or regulation; however, there are no Federal restrictions on same-day billing for physical and behavioral health visits.

Practices should establish policies related to patient payment for medications and other services and set clear expectations with patients during the intake process. Unfortunately, patients may experience barriers to obtaining medications for opioid use disorder through Medicaid and private insurers. States’ Medicaid programs vary widely in how they cover and reimburse for MAT services. However, strategies and tools are available so that practices and providers can help.

Lack of insurance. If patients do not have insurance, providers should explore whether they are eligible for Medicare or Medicaid. Some larger organizations may have case managers available to help patients obtain health insurance while smaller practices may be able to identify community-based services to help patients.

Choice of medications. All State Medicaid programs reimburse for some form of medications to treat opioid use disorder.³ Although the Affordable Care Act requires most insurers to cover substance use treatment services, not all insurance plans will cover every medication or formulation available. For example, in 2018, fewer than 70 percent of State Medicaid agencies covered implanted or extended-release injectable buprenorphine.¹

While choosing a medication should be guided by a patient’s needs and preferences, providers need to consider the extent to which medications are covered by insurance. For example, newer brand medications can be very expensive and less likely to be covered by insurance. As of 2018, the following medications did not have a generic version available: subdermal/implant buprenorphine, extended-release injectable buprenorphine, and extended-release injectable naltrexone.¹ If patients cannot pay for medication, it may be harder for them to stay in treatment and may increase their risk of overdose.

If a patient’s insurance does not cover a medication that is clinically indicated and preferred by the patient, providers may also help the patient apply for a patient assistance program through a pharmaceutical company. Also, some States may have low-cost drug programs for those who are not eligible for Medicaid but still fall below a designated income threshold.

Utilization management policies. Many private and public payers implement restrictions on the services and medications that can be covered to treat opioid use disorder. In theory, these benefit design limits and utilization management strategies are meant to ensure treatment is appropriate and cost-effective. However, in practice, such policies often slow or restrict access to much-needed medication or services.

Prior authorization is a process in which payers require providers to obtain advance approval before billing for a medication prescribed to treat opioid use disorder. Among State Medicaid programs in 2018, prior authorizations were most commonly required for buprenorphine (40 States) and buprenorphine-naloxone (31 States). Prior authorizations may be required for buprenorphine monotherapy because of its potential for misuse.¹ In addition, medications that are more expensive may also require prior authorization, including extended-release injectable naltrexone (19 States) and extended-release forms of buprenorphine (about half of States).¹

Also, some payers may hinge approval of prior authorization on the patient’s participation in psychosocial treatment. Providers may be required to submit evidence that a patient has been referred to or is engaging with psychosocial treatment before receiving approval and reimbursement for the medications from the payer. However, the decision to engage in behavioral therapy or psychosocial support should result from shared decisionmaking between patient and provider. Some patients will be interested in this component of treatment while others may not yet be ready or feel it is necessary for their recovery. Prior authorizations that are contingent on participation in behavioral therapies conflict with expert recommendations not to limit access to medication because a patient is unwilling or unable to engage in behavioral therapy or psychosocial support.¹

The prior authorization approval process can sometimes be quick but may take days or weeks. This process can be disruptive and burdensome for both providers and patients. Fast access to treatment can be very important for people with opioid use disorder facing withdrawal symptoms, and interruptions in workflows may lead to lost revenue for practices,³ in addition to the lost opportunities to provide needed services.

During implementation planning, practices should develop processes and protocols to check prior authorization requirements before providing services or sending prescriptions to the pharmacy during intake and before medication refills. The American Medical Association provides tips to help physicians reduce the prior authorization burden(This link will open in new window) (PDF—310 KB). These processes and protocols should clearly identify the following³:

• Who is responsible for prior authorizations.
• What information needs to be documented in the medical record for prior authorizations.
• How prior authorizations will be submitted and tracked to ensure timely approval.
• How to submit an appeal for denied services or medication.

Despite increased efforts to automate the process through electronic health records and to standardize requirements across health plans, significant progress still needs to be made.³

Step therapy is another benefit design strategy in which patients are required to try a first-line medication before they can receive a second-line medication.¹ This strategy may be across medication types, formulations, or brands. For example, payers may take a “fail first” approach in which a patient may be required to try a generic medication first before a branded medication.

Payers may also impose treatment limits to manage costs, such as setting a maximum quantity or dosage of medications that are covered by a prescription or copayment. Unfortunately, such cost-driven strategies may not be consistent with clinical best practices and may constrain what treatment is possible, so it is important to be aware of such payer requirements. Perhaps over time it may be possible to convince payers to move toward strategies better aligned with the evidence base for effective treatment.