Insurance & PQ
How Insurance Works at PQ
PQ has designed a therapeutic program around your family’s individual needs, not your insurance provider. For this reason, PQ is not in network with any insurance providers, and coverage is never guaranteed.
However, in most cases, if your plan has good out-of-network coverage, we can secure coverage for some portion of your stay. Here’s how it works: Insurance Fast Facts
Apply to PQ
It all starts with a phone call: 808-937-5806. Our non-commissioned admissions team is ready to answer your questions, learn more about your situation and goals, and discuss options.
Complete a VOB
Once your application is approved, our third-party insurance billing company will complete a verification of benefits. This helps us understand your available benefits, including your deductible, coinsurance, and any limitations that may affect coverage.
Arrange Enrollment
Provided we all feel this is a good fit, we’ll book travel and arrange for enrollment.
Prepayment of Cash Pay rate
PQ will collect a prepayment of the Enrollment Fee and 45 days of the cash-pay daily rate of $1100/day. These funds are set aside for any days not covered by insurance.
Pre-Authorization
Shortly before arrival, using the clinical information we learned through the application process, we will request pre-authorization through your insurance. While this does not guarantee coverage, it allows us to begin billing your insurance at enrollment.
Enrollment
Our team will inform your insurance provider that you’ve enrolled and begin the claims process.
Continued requests
Generally, insurance will only authorize 3-7 days of treatment at a time. We’ll keep pursuing coverage for as many days as possible.
Denial
Eventually, insurance will deny coverage. On average, this occurs between 30 and 45 days into treatment. You can do a quick appeal (free) and then a longer appeal (Additional fee). We’ll discuss whether this makes sense when that time comes.
Claims Processed & Paid
PQ will begin submitting claims within a week of admission. Sometimes claims can finish processing before departure, but more often we see them finalize just before or shortly after departure. Claims are billed in multiple segments over several days.
In most cases, claims are paid directly to PO. But in some cases. your insurance may send a check to you. If that happens, please send us a copy of your explanation of benefits (EOB) and a copy of the check so we can calculate your reimbursement.
Reconciliation and Reimbursement
Our 3rd party billing partner collects 10% of all insurance funds collected. You are responsible for the fees on any reimbursement you receive. PQ must also withhold your deductible and coinsurance. Non-covered services and state tax. You’ll then be reimbursed for the covered days at the cash pay rate you pre-paid. Per your insurance carrier, you must pay Pacific Ouest within thirty days of the check date.
Things to Keep in Mind
- Insurance is complicated! That’s why we’ve partnered with 3rd party partners to ensure the best possible chance for insurance coverage. If PQ hired an internal team to manage the insurance billing, we’d need to increase our fees much more than the commission our billing partner charges.
- Because insurance will only authorize a handful of days at a time, we will never know in advance how much coverage your family will receive.
- PQ builds its treatment experience around our families needs, not insurance. This boutique approach to residential treatment requires robust staffing, training, and highly educated professionals to provide safe effective care. The Discounted Cash Pay rate is not the rate that covers the cost of this kind of treatment. The higher rates occasionally afforded by insurance allows us to offer a reduced rate for families for the days that are not covered. This ensures families can afford a full treatment experience.
- Insurance coverage works by the days covered, not the dollar amount. This means that it’s against the law for us to apply funds from a covered day of treatment to a non-covered day of treatment.
- It’s in our mutual interest to get as many days covered as possible. This lowers your overall cost and helps PQ continue to offer the discounted cash pay rate.
- Due to taxes, billing partner fees, deductibles, co-insurance and non covered services means that even in the rare event that every day of treatment is covered, you will still have out-of-pocket costs.
