Billing for Autism

We recently had someone ask us to post about diagnoses that are hard to get services reimbursed for, specifically mental health diagnoses. It is not terribly common, at least not in our experience, but it does happen. Some insurance plans, such as self funded plans, actually spell out exactly what they will and will not cover, sometimes right down to the diagnosis. It seems like it should be discriminatory but it isn’t.

We actually billed for an individual counseling session, 90806, with a diagnosis of 314.01, Attention Deficit Disorder of Childhood with Hyperactivity. It was denied stating it was not a covered service. The plan was administered by our local Blue Cross Blue Shield. Not understanding why it wouldn’t be a covered service we called the customer service line to inquire why. We were advised that the cpt code 90806 was not a covered service under that plan with a diagnosis of 314.01. They explained that it was a self funded plan and that they specifically had outlined that ADHD was not a covered diagnosis for mental health treatment and that there were no appeal rights.

We have heard from others that this has happened to them with a diagnosis of Autism. We personally haven’t experienced that diagnosis being denied. Like I said, at first glance it seems discriminatory. There are all kinds of laws out there trying to make mental health services equal to medical services. Unfortunately most of these laws are enacted due to very horrible circumstances. For example, in New York State they enacted Timothy’s Law after the unfortunate suicide of a young man who was denied coverage for mental health services by his insurance carrier.

These laws don’t help with this situation because it isn’t that the mental health services are being denied, or even not as good as the medical coverage. It is only certain diagnoses that are not covered. Therefore, they are not denying mental health coverage to the patient. Also, we have found that there are no appeal rights since it is a plan exclusion. It is not that they are determining it on a case by case basis.

It is not only mental health that this is happening. We have also seen it happen to services billed by optometrists as well. It just seems that with mental health it is more discriminatory since mental health services have been fighting to be seen as medical for a long time. I wish I had better advice to give to people who have experienced this issue. Unfortunately this is an area where all hands seem to be tied.

If you have had any experience with this type of thing, we would love to hear from you.


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