Do Insurances Reimburse Ketamine Infusions?
Research supports that ketamine infusions are an effective treatment for mood and pain disorders. So health insurance plans should cover them right? Well, yes and no. 😅 Confusing right? In this blog post, we’ll cover what the current state of outpatient ketamine infusion reimbursement looks like and what our experience has been. Hope this helps all you budding ketamine infusion doctors!
Are Insurances Reimbursing Outpatient Ketamine Infusions? The answer isn’t as simple as it seems.
Are Insurances Reimbursing Outpatient Ketamine Infusions?
Mostly no. The reimbursement for outpatient ketamine infusions are all over the place. The sad truth is that a majority of insurance companies are not covering outpatient IV ketamine treatments. The biggest challenge is that ketamine infusions for the treatment of mood disorders like depression are not FDA approved (it’s an off-label use). Therefore the insurance companies argue ketamine treatments are too experimental and that it shouldn't be covered.
Things are s l o w l y changing as some health insurance companies realize the benefits of off-label ketamine use. Again, there is much variability in coverage and better luck with certain pain conditions (e.g. CRPS/RSD). It'd be wise to consult a billing specialist who knows how to navigate the complex reimbursement scheme of insurance.
Ironically, intranasal esketamine is covered by insurances despite it being less effective than ketamine infusions.
Intranasal Esketamine is an Option
Ironically, nasal esketamine (Spravato from Janssen) is covered since it's been recently approved by the FDA for depression. However, the provider and patient have many obstacles (e.g. failed 3 meds, currently be on psychiatric medication, clinic has to be a REMS provider, pt has to be observed in clinic for 2 hours afterwards).
Frankly this sounds like a lot of work for a treatment that research shows is less effective than infusions. However it shouldn't stop you from adding esketamine to the services you provide if you already have a clinic. You should consider if you have the capacity to follow the requirements and the staffing to do the legwork (i.e. a billing insurance person and the medical staff to monitor the patient after).
Despite the lack of support from insurance companies, some ketamine clinics find a way to still bill insurances.
What Some Ketamine Clinics are Doing
Despite the lack of consistent reimbursement by insurances, there are ketamine clinics that are still billing insurances. How are they doing it? Some ketamine specialists are in-network and can bill the insurance for a regular visit. Then they will have the remainder paid by the patient out-of-pocket. Also, depending upon the specialty, they will have different CPT codes to use. For example, in-network psychiatrists can bill for new psychiatric evaluation (CPT: 90792), established psychiatric eval (CPT: 99214), psychotherapy add-ons (CPT: 90833-90836), and the patient will pay the rest.
If you have the staff who can support you, then it may be worth it for them to spend the extra time doing more research with the specific insurance companies that you are already contracted with.
We also have our own experiences in dealing with insurance companies.
How We Deal With Insurance
At our clinic, we let our patients know that we can provide a superbill and they will spend their own time to potentially seek reimbursement after they get the treatments. Unfortunately, it hasn't been very successful. (Caveat, I'm a solo practitioner and by no means an expert in medical coding/billing nor at this time are we in-network for any insurance companies).
We also don't provide nasal esketamine (Spravato) simply because as we mentioned above, it's simply not as effective as generic IV ketamine. Read the systematic review & meta-analysis here.
We have faith that insurance companies will someday start covering ketamine treatments.
Someday Things Will Change
Reviewing the research and witnessing the changes we are seeing in our patients lives, we have no doubt that ketamine infusions are an effective and life-changing therapy in the right patient. And because of this, we have faith that insurance companies will come around and start covering this treatment. When that time comes, we predict the demand for ketamine providers will skyrocket.
The question is, do you want to be able to meet the demand? Do you already want to be a ketamine expert with lots of experience? Do you want to help change patients’ lives?
If you answered “yes,” then we're here to help you. Whether that is guiding you on how to start your own clinic or adding ketamine infusions to your already existing practice. We can teach you how to provide ketamine infusions in a sustainable and life changing way!
Join our email list and be notified about the next free webinar and open registration for Ketamine StartUp to get started!
Ketamine infusions are an effective treatment for mood and pain disorders. Unfortunately, reimbursements for these treatments can be quite a challenge. Read our blog to find out whether ketamine infusions are covered by insurances.
Discover 3 essential questions every EM physician should ask before starting a ketamine clinic to help guide your decision and next steps.