What is Partial Hospitalization?
A structured mental health treatment program that runs for several hours per day, from three to five days per week, is known as a Partial Hospitalization Program. Those enrolled in Partial Hospitalization Programs will participate in scheduled sessions during the day, returning home at night. Partial Hospitalization Programs are considered a “step down” from 24-hour care as an inpatient in a psychiatric hospital. In some cases, Partial Hospitalization is used as a preventative measure against a lengthy inpatient hospital stay. A mental health professional will conduct an evaluation to determine whether Partial Hospitalization is right for you. This mental health professional will assess you based on the following:
- Are you at risk of harming yourself or others?
- Overall, are you considered medically stable?
- Do you have an adequate support system at home?
- Are you motivated to participate in this type of treatment program?
- Have you demonstrated difficulty in functioning at work or school?
- Are you experiencing both mental health and substance abuse disorders?
A “typical” day in Partial Hospitalization might include skill-building practice, individual therapy, group therapy, and periodic evaluations. If medication is required, you will meet with a staff psychiatrist. Family therapy may also be a part of the Partial Hospitalization experience. Transportation to and from the program may be provided, along with lunch. Teens that enter Partial Hospitalization will have schooling in their program as well to prevent them from falling behind.
How Long Does Partial Hospitalization Typically Last?
Considered a short-term treatment, Partial Hospitalization usually lasts from one to four weeks. The goal is to improve enough to be transferred to a lower level of care like intensive outpatient treatment. The program is structured to assist in the transition from inpatient to outpatient treatment and is most appropriate for those who:
- Require more intensive treatment than outpatient programs typically offer
- Have been diagnosed with mild to moderate emotional or psychiatric disorders
- Require multidisciplinary treatment that is coordinated, comprehensive, and intensive
- Present no immediate threat to themselves or others
- Can maintain themselves in the community
Does Insurance Cover Partial Hospitalization?
At least a portion of your PHP treatment is likely to be covered, but you may need to meet a host of requirements, including prior authorization from your primary care physician. As a result of the Affordable Care Act, most policyholders have greater access to mental health and substance abuse treatments, including PHP. Further, pre-existing conditions, including substance use disorders and mental health issues, must be covered. This is not to say that your insurer will necessarily cover all of your Partial Hospitalization Program. Your plan may place a limit on the number of sessions they will cover during a given time period, you may require prior authorizations for certain services, and you will still be required to pay your deductible and co-pay.
Having an in-network provider will likely increase your level of coverage. In some cases, an insurer will compare your case to other patients facing the same health issue, then cover the average number of days others have spent at a hospital for the same condition. Other services may not be covered if your insurer decides it is safer for you to receive the service only as a part of an inpatient program. The flip side of that is that some insurers will require you to first attempt an outpatient treatment like PHP before they will cover inpatient treatments. If your insurance company won’t approve a Partial Hospitalization Program, it is important to speak to a knowledgeable PHP insurance denial attorney from the Law Offices of Scott Glovsky.
Why are Partial Hospitalization Program Claims Often Denied?
Your insurer may determine that a PHP is not “medically necessary” in your case, therefore, deny the claim. Any insurer can deny a PHP claim, although some insurers may be more likely to do so. It is important that you follow your plan’s pre-authorization rules to the letter. If you receive an initial denial for your PHP treatment, your primary care physician may be able to re-submit the treatment plan with a letter outlining why the PHP is medically necessary. Anthem Blue Cross, Blue Shield, Health Net, Kaiser, UnitedHealthcare, Aetna, and other insurers may deny a PHP claim. If this occurs, you need a strong advocate in your corner who will fight for the treatments you need. That advocate is attorney Scott Glovsky.
How Scott Glovsky Can Help with your Partial Hospitalization Program Insurance Denial
Attorney Scott Glovsky has a stellar track record of success when helping those who have been denied necessary treatments by their insurance companies. While Scott approaches every case from a human point of view, his results speak louder than words. When you choose the Law Offices of Scott Glovsky, you can rest assured you will receive the highest level of legal advocacy, along with personal care and support. Our mission is to help those who have been wronged while listening to and supporting their needs. If you need help with a Partial Hospitalization Program insurance denial and want to be treated with dignity and respect, contact the Law Offices of Scott Glovsky today.