Solving the Insurance Puzzle: How to Get Your Ketamine Therapy Covered
Ketamine treatment for depression, anxiety, PTSD or chronic pain are not approved by the FDA. However, if done well, ketamine treatments are a safe and legal off-label treatment, supported by growing evidence suggesting ketamine can help certain people with chronic pain or mood disorders.
Spravato, the intranasal ketamine spray, is usually covered by insurance.
However, ketamine lacks official approval for mental health or pain and insurance companies generally will not reimburse them in the United States and Canada.
For those who need or want to try ketamine treatments or infusions, the situation is frustrating. However, options exist. In this article, we cover skillful billing and how businesses help employees get psychedelic therapy. We got the facts by talking with those who know ketamine and insurance interactions inside and out.
There is hope. It just lies inside the complicated world of medical billing. And a solution that sounds like a comic-book hero:
A superbill is a detailed invoice provided by healthcare providers to patients after a service is rendered. It contains all the necessary information for the patient to submit a claim to their insurance company for reimbursement. In essence, a superbill is like a receipt, but with added medical and insurance-specific details, helping patients get their treatments covered by their insurance plans.
A Personal Story of Pain
“I was a captain in the US Air Force. I was a nurse practitioner, and I unfortunately got injured during a training exercise,” says Kimberly Juroviesky, founder of Ketamine Taskforce, a nonprofit patient advocacy group. “The injury led me to develop a disease called Complex Regional Pain Syndrome (CPRS). It’s considered one of the most painful diseases on the planet. And for me, the only thing that helps all the pain is ketamine… I would not be here without ketamine. For me, it literally saved my life.”
The revelation came after participating in a research study. After the research ended, Kimberly needed to continue treatment. In some cases an initial series of ketamine treatments can offer rapid and lasting reduction in symptoms, however most cases–like Kimberly’s–require ongoing “boosters” to maintain relief.
“Very few people were doing it back then (2015). So I ended up starting a Facebook group to connect with others being treated with Ketamine Infusions both for pain and for mental health,” she says. Juroviesky’s group continues to grow. “Through that group, I realized that there was that huge issue of lack of access for many people due to insurance companies not wanting to cover ketamine.”
Getting reimbursement for ketamine means understanding and deftly navigating the language of insurance.
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How Much Do Ketamine Infusions Cost?
A medical professional must administer ketamine, and they usually do this in a clinic.
A single infusion runs between 350 to 1500 dollars, depending on the condition. Infusions for pain are usually more. Typically, a clinic is going to recommend at least six infusions. Add boosters and costs quickly spiral into the thousands, sometimes without integration therapy included. Ongoing psychological therapy will also help make ketamine more effective for most people. All of these have associated costs which quickly add up.
Why Isn’t Ketamine Covered by Insurance?
When the FDA approves a drug for legal use, it is for a specific application. Ketamine is only approved as an anesthetic agent for surgical and diagnostic procedures. The FDA has not approved ketamine to manage chronic pain or for the treatment of any psychiatric disorder.
The Food and Drug Administration is unlikely to approve any new uses of ketamine in the years ahead without costly research to back it up. Most drug studies are funded by companies looking for new patentable drugs which treat a specific condition. The FDA granted the patent on ketamine as an anesthetic way back in the 1960s. That patent expired long ago. This means that, from a financial standpoint, there is little incentive for a pharmaceutical company to go through the expensive process of FDA approval.
Doctors prescribe ketamine “off-label” as a treatment for mental health or pain. Ketamine will remain off-label for mental health and pain unless someone completes extremely expensive trials; thus, patients will need to self-pay for ketamine.
“Drugs are used off-label every single day of the week. But insurance companies can pick and choose” what they pay for, says Juroviesky. If ketamine is never approved by governing bodies like the FDA, AMA and Health Canada, it will always be viewed as “experimental” in the eyes of insurance, and therefore companies won’t pay.
How to Get Ketamine Covered by Insurance
Getting insurance to pay for ketamine is tricky. Again, most major providers, including Medicare, will not cover ketamine for mental health or pain.
However, there are some ways to navigate the current system to receive some reimbursement for ketamine.
First, it’s important to grasp how billing for treatment works.
With a few exceptions, ketamine clinics will be “out of network,” meaning they have no direct relationship with your insurance company. In-network is rare, but exists, notably with Massachusetts leading the way by insuring ketamine infusions. So, the first step is checking if your plan is in-network with any ketamine providers.
For most of us, getting ketamine will occur out-of-network. We then need to check how an insurance plan deals with out-of-network billing. Most insurance companies will accept bills from out-of-network clinics but be sure to check specific benefits for individuals or family members. Note your deductible and perhaps out-of-pocket maximums too.
Before starting ketamine treatment check if your insurance provider will require prior authorization. For expensive treatments, an insurance provider may want to approve a treatment beforehand. Get to know this process well, as mistakes on paperwork can slow the process.
The tricky part here is mentioning ketamine will in many cases result in zero reimbursements.
However, some plans may cover consultation and therapy, even if the ketamine itself is not covered.
Billing Insurance for Ketamine Treatments with a Superbill
To better understand how to bill for ketamine, we reached out to Carlene MacMillan, Chief Medical Officer at Osmind, a public benefit corporation and electronic platform clinicians use as an electronic health record.
Osmind helps clinicians optimize care in a number of ways. But one feature in particular has made the service popular for ketamine clinics—the Superbill.
“[The Superbill] outlines the services a therapist or healthcare provider has performed for a client during their visit,” explains MacMillan. The bill is a list breaking down all the different parts of ketamine treatment. Think consultations, infusions and therapy. These are all typical items to submit to insurance companies.
“Unlike traditional medical receipts, a Superbill contains essential information such as diagnosis and procedure codes. These codes are crucial for insurance payers to determine the appropriate reimbursement for the services after the patient has made the initial payment.”
MacMillan breaks down how the codes are Current Procedural Terminology codes or CPT codes. On a bill, you cross-reference these codes with the diagnosis for which a procedure is performed. For example, CPT 96365 is the primary code for infusions up to one hour, and some ketamine clinics will use this code to get reimbursement.
However, putting down the right code doesn’t guarantee full reimbursement. This is because each ketamine provider will have a specific charge for every CPT code.
In contrast, individual insurance plans have different allowable amounts they reimburse for each code, known as the usual and customary rate. However, in the case of ketamine treaments for a depression diagnosis, many insurance providers will not reimburse anything.
“Some aspects of the care, including the consultation, are generally eligible for reimbursement and some more progressive insurance companies (covered below) are starting to cover IV ketamine for psychiatric conditions,” says MacMillan. She adds that “patients can call the insurance company with the list of codes used and sometimes plans will state how much they typically reimburse.”
Checking with the insurance company and the ketamine provider is important. MacMillan says that insurance companies “often reimburse patients at a fixed percentage of the ‘usual and customary rates’ regardless of what the practice charged. This can result in lower than desired reimbursements.”
If this is starting to sound complicated, it’s because it is.
Hence using Superbills to break everything down into manageable chunks. Hence many electronic health record programs developing services to generate Superbills. Be sure to understand how a ketamine provider handles billing, and if a Superbill will be available. It also can be helpful to be familiar with Osmind’s ketamine billing code guide, for optimizing reimbursement.
In the event of a denial, MacMillan recommends carefully reviewing any error codes and talking with the ketamine provider and insurance company. Appealing a denial is possible often by submitting documents showing why a procedure is medically necessary.
Juroviesky has learned in her Facebook groups that some insurance companies have sent out cease and desist letters to providers after learning patients were using ketamine. While this seems to be rare, providers were asked to repay the benefits claimed. It is unclear how billing was handled in these situations and MacMillian emphasizes that:
“It is the responsibility of practices to understand what a given insurance company allows before providing superbills as if they go against the rules, they could face repercussions.”
What Services Does Insurance Cover?
|Treatment service||Length of time||Eligible for reimbursement?*||How much does it typically cost?|
|Ketamine medicine — given by injection, infusion, or lozenge||Variable||Almost never, except for Spravato||$90 and up|
|Intake with prescriber (doctor or nurse practitioner)||30-90 minutes||Usually, if someone has out-of-network benefits||$300-$1000|
|Intake with therapist||1 hour||Sometimes||$150-$250|
|Followup check-ins with prescriber||15-30 minutes||Sometimes||$150-$400|
|Group therapy sessions||45-90 minutes||Sometimes||$50-150|
Getting Full Insurance Coverage for Ketamine
While superbills are the standard at the moment, Enthea, a public benefit corporation is pioneering a nationwide benefits package for psychedelic-assisted therapy.
“You can think of it [in terms of] how employers have dental or vision plans, which are add-ons to the basic primary care benefit they give to their employees,” says Sherry Rais, co-founder and CEO of Enthea. “Usually you get your health care from someone and then your dental from someone else and your vision from someone else. And now [you can get] your psychedelic care from Enthea.”
Enthea made headlines when Dr. Bronner’s soap company unveiled 100 percent coverage for ketamine-assisted therapy for all employees through Enthea. The decision came after President Michael Bronner’s success with ketamine.
“I don’t want to oversell ketamine therapy as a miracle cure, but it just stripped the rust away, gave me a reset and got me to a really good space,” Michael Bronner told Enthea, comparing the experience to a massage of the brain, clearing away angst and despair. Not long after, other employees had positive experiences too.
Whether an employer has five employees or 100,000, they can design custom plans, Enthea says. Currently, Rais says they are seeing 70 percent to 100 percent coverage. She thinks some employers might end up offering 50 percent coverage or perhaps a copay option.
“We have a nationwide network of providers. And we work with the employer to make it affordable,” Rais says. “So there are different ways to structure the plan so that it doesn’t end up costing the employer too much. It could cost as little as a few dollars per employee per month.”
“We have a credentialing process and a medical policy,” explains Rais. “We work with clinics to put them in-network first by talking to them and building relationships. And more importantly, vetting them and credentialing them according to certain standards.”
Very few employees are lucky enough to currently have this option. When asked how employees should approach an employer about Enthea, Rais says, “Mention to their employer that this exists, and then they can put them in touch with us and we can do the convincing or really educating.”
Will Insurance Cover Ketamine Therapy?
So, in sum, while parts of the ketamine treatment may be covered by some insurance, the ketamine itself is typically not covered. Juroviesky and KetamineTaskforce, however, are taking matters into their own hands.
“We’re looking to get ketamine on-label for major depression with the FDA,” she says. The vision is to do a trial that will enroll 300 veterans and use a set protocol developed with over 25 doctors, CRNA’s and nurse practitioners, that other providers can use going forward. “We’re super excited about it. We’re hopefully going to be working with two or three universities and 7 Ketamine clinics around the state of Florida to do this trial.”
This is an ambitious plan, as the trial will take lots of time, and yes, a lot of money. Juroviesky believes the trial will take about three years to complete.
Other Options for Accessing Ketamine Treatment
Despite the ingenuity of many well-intentioned people, the fact is, ketamine remains an out-of-pocket expense. However, there are other ways to access ketamine.
Discounts and Insurance Coverage for First Responders and Veterans
Depending on the state and clinic, a few Department of Veterans Affairs (VA) cover ketamine treaments, and many will cover Spravato treatments. Sometimes you can access treatment locally through the VA Community Care Network and the specific clinics associated with a branch.
Some clinics will also offer partial discounts or sometimes even free treatments to paramedics, firefighters, law enforcement or other first responders. Check a clinic’s website to find out if you qualify for a discount.
Many clinics will also have partnerships with third-party brokers who can finance ketamine treatments. Plans and interest rates vary, so be sure to check the details to find what is manageable in your situation.
If you intend to finance ketamine with the assumption your insurance provider will reimburse you, do your homework! Speak with your insurance company and get extremely clear about what you will be eligible to claim.
Costs for Other Ketamine Treatments
If you think ketamine is right for you, be sure to check out some other routes of administration or perhaps telehealth services.
How Much Does Intramuscular (IM) Ketamine Cost?
Doctors inject ketamine into the muscle for intramuscular treatments, not into the vein. Intramuscular injections usually cost about the same as intravenous ones, but you might find them slightly cheaper by up to one hundred dollars in some cases.
A medical professional must perform the injections, and costs associated with IV treatment, such as consultations, time in a clinic, medical supervision, and therapy, still apply.
How Much Does Intranasal Ketamine Cost?
Johnson & Johnson holds the patent for the ketamine nasal spray known as Spravato, specifically for the treatment of treatment-resistant depression.
Johnson & Johnson spent an enormous amount of money to patent esketamine, a slightly different version of traditional ketamine. Studies showed their esketamine nasal spray, which they called Spravato, was effective for treatment-resistant depression.
The FDA, Health Canada, and other governing bodies approved the drug. The approval made Johnson & Johnson the only company allowed to sell intranasal esketamine for treatment-resistant depression. Until the patent expires, the company makes a profit from all Spravato used and can offset immense research costs.
For people diagnosed with treatment-resistant depression, insurance can cover Spravato, but you should check first. Without insurance, Spravato treatment will cost as much or more than infusions or injections, depending on frequency.
How Much Does Oral (Sublingual) Ketamine Cost?
Doctors give oral ketamine in the form of “troches” or “lozenges,” which are tablets that dissolve under the tongue. Troches are by far the cheapest ketamine option, with monthly plans available for around 100 dollars per month. Oral ketamine takes longer to work and the bioavailability of the drug is lower. You can use telemedicine platforms for this method, or for maintenance doses.
In a similar way to ketamine infusions, when it comes to ketamine therapy, insurance may be more likely to pay for the therapy than the ketamine. Innerwell, an at-home ketamine therapy company, can provide a superbill to submit to insurance companies. That way, insurance might pay for the medical intake or psychotherapy follow up appointments–even if the ketamine itself is not reimbursable.