For many people seeking treatment for substance use and mental health, getting insurance to cover the services proves vital to their ability to access care. That said, insurance companies can make this difficult, and coverage for substance use and mental health tends to vary widely.
For most insurance companies, authorizations are required to get intensive outpatient or residential levels of care covered. These authorizations are based on medical necessity, which considers specific insurance policy requirements and limitations. This process is far from a black and white process and requires significant clinical knowledge and expertise to navigate effectively.
To convince a Health Insurance company that someone needs treatment, a licensed clinician at the treatment program must speak with an “equivalently credentialed individual” at the insurance company. At Sandstone Care, we have a dedicated clinician who spends her days relentlessly advocating on behalf of our clients and families.
Enter the world of Heidi Peveto, Utilization Review Coordinator extraordinaire at Sandstone Care. Most people’s eyes glaze over when they hear the words utilization review. Could a term be any more dry and vague? However, whether you understand it or not, Heidi’s work behind the scenes to make treatment accessible to people is nothing short of heroic and is a core value of our organization (Accessibility).
A so-called Colorado native, Heidi has found her niche in the therapy world. She brings a rare combination of the compassion to help others and a thorough understanding of both the clinical and the insurance worlds.
Heidi was first exposed to the human services field when she took on an internship in Germany working with refugees. Seeing the trauma that many refugees experienced compelled her to get her undergraduate degree in psychology and her masters in clinical counseling. In her clinical internship, she found herself drawn towards the assessment process.
Heidi recognized that the initial assessment dictated the level and type of treatment that a client receives. If someone is diagnosed with oppositional defiance disorder (ODD), but in reality, they are struggling to connect due to severe trauma, this may direct the treatment in the wrong direction.
Heidi worked with the Tennyson Center for Children for 5 years, where she supported a population that had significant trauma. Many of the adolescents she worked with were also in legal trouble, and she advocated for treatment over punishment. She also managed the crisis support line, rotating through shifts of being on-call day and night for a week straight.
As much as she loved working with the Tennyson Center, Heidi needed a break from the intensity. Her passion for advocating for high-quality treatment was undiminished, so she packed up all of her talent and experience and brought it to us a Sandstone Care. Heidi manages then entire utilization review process for Sandstone Care.
When Sandstone Care gets a call from a potential client, we are committed to getting them connected to the best care for them. For one person that may be directing them to programs that accept Medicaid, or work with an older population than we do. For other callers, it may just mean explaining their options and equipping them with good information on what to look for in a treatment program.
When Mark, a hypothetical 23-year-old client, calls our admissions team, he seems like a good fit for us. We want to make treatment as affordable as possible, while still clearing the high bar we have set. Our admissions team asks for Mark’s insurance information so that we can talk to the insurance company for an initial verification of benefits (VOB). In Mark’s case, he is still on his parent’s insurance plan with Anthem Blue Cross Blue Shield, so he provides us with the necessary information and we let him know we’ll follow up shortly. The VOB lets us find out if Mark’s family’s plan has coverage for behavioral health and substance use treatment and what their outstanding deductible and co-insurance will be.
We relay this information back to Mark’s family and if they want to go forward, we bring them into our office for an assessment with Brittany Miller. Brittany is the assessment coordinator for our Denver location. As mentioned above, the assessment process is a key step in the process of getting the right treatment. For that reason, we allow assessments to take as long as they need to, often at least 2 hours. We get a thorough history from Mark as well as any family members who can attend the assessment.
Brittany will provide an honest recommendation for which level of care they deem most appropriate for Mark’s family. At Sandstone Care, we want to make sure that each person is getting the best care for their current needs, even if that means referring them elsewhere. When Mark begins programming with us, Brittany passes her assessment of Mark on to Heidi. Heidi prepares for a call with Anthem, Mark’s insurance company, to advocate for the need for treatment.
Often underappreciated by families, insurance coverage for treatment now depends on Heidi’s ability to walk the knife-edge ridge of communicating Mark’s need for treatment at the day treatment or intensive outpatient level of care. If she is too dramatic, Anthem will argue that Mark needs inpatient treatment and potentially deny coverage. If, however, Heidi doesn’t convincingly articulate the risk of Mark’s situation, Anthem may decide not to cover him at all.
Luckily, Heidi Peveto is ideally equipped to handle the pressure. Accustomed to walking actual knife-edge ridges as a mountaineer in the rugged Colorado Rockies, she knows the importance of being prepared and focused. She uses her clinical experience of working with people in crisis to remind Anthem’s clinician on the other end of the phone how essential it is to get Mark into treatment while he is motivated to get sober and before a higher level of care becomes necessary.
Based on Heidi’s conversation with a clinician at Anthem, they authorize a specific number of treatment days that they deem to be “medically necessary.” Usually, the amount of time authorized is a conservatively low estimate. While Mark is doing well in Sandstone Care’s intensive outpatient program, neither he nor the clinical team feel that he is ready to step down to our outpatient group.
To keep Mark in the program, Heidi gears up to advocate for continued coverage. She calls back and again walks the line of communicating Mark’s progress, yet continued need for support at the intensive outpatient level. If all goes well, Heidi can report to the team that Mark can continue his strong work.
This process often happens several times for each person in our program. Heidi doesn’t always emerge victoriously. Some insurance companies are easier to work with than others. If we are in-network with an insurance company, they have vetted us thoroughly already, so there is more implicit trust making Heidi’s conversation more straightforward. Other insurers are stingy in handing out treatment days. Heidi derives satisfaction from a successful phone call with an insurance company.
She excels at putting the puzzle pieces in place to get our clients the care they need at minimal out-of-pocket costs. Just like the meticulous planning that goes into a challenging mountain climb, she prepares for each phone call. Heidi tracks the progress of each of our clients and continuously expands her already impressive knowledge of the clinical world.
Many of our clients don’t even know her name, but she is every bit as important as the primary therapists in our goal to inspire and empower change. Change doesn’t happen overnight, and if Mark can’t stay with us long enough to develop new habits that will keep him sober long after he moves on from Sandstone’s care, then we haven’t lived up to our mission statement. Fortunately, Heidi comes through again and again for us by getting people like Mark through our program so that he can inspire us with his ability to change.
Heidi’s next mountain? The third trimester of pregnancy. Based on her track record, we’re confident here at Sandstone Care that the world is about to be blessed with a very lucky baby.