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How Much Do Insurance Providers Reimburse for Spravato?

In a short time, Spravato therapy has become one of the most sought after therapies among treatment-resistant depression patients. Studies reveal the potency of Spravato in relieving the symptoms of  treatment-resistant depression and acute suicidal ideation among adults. However, at the same time, Spravato is not readily available to everyone seeking it. Availability of the Spravato drug and access to the treatment are controlled under strict regulations from the authorities.

Another hurdle in receiving Spravato therapy is that the treatment is highly-priced. Since the drug is administered under Risk Evaluation and Mitigation strategies, it is not sure how far the insurance reimburses for Spravato. Plus, healthcare providers are caught in a dilemma on how to bill claims for Spravato. In such a scenario, practitioners are forced to demand patients pay out of their pockets. It sure puts healthcare providers and patients in a tough spot. And, the questions remain—how much cost of Spravato insurance reimburse? And, how much does Spravato cost out of pocket for the patient by going with the conventional way of billing?

Issues faced by the providers in handling insurance reimbursements for Spravato


Many healthcare providers are finding it difficult to keep their Spravato practice cost-effective. The reasons are simple:

  • There are no standardized practices established on determining the reimbursements, co-pays and deductibles.
  • The pre-authorization process takes a long time  due to the complex application process, thus, delaying the treatment further.
  • Coding for Spravato claims is not well defined and buying the Spravato doses requires another load of paperwork.

Practolytics offers Spravato–specific consultations to troubleshoot your problems in establishing a smooth-running Spravato practice. Being one of the pioneers in the industry, we make sure you get paid for all the valuable services rendered. We help practices in developing the right clinical protocols to obtain maximum insurance reimbursement for Spravato. Since the payment for the two-hour-long monitoring period after Spravato administration is often overlooked at the time of reimbursement, we can help you in modifying your billing process to match the requirements of the payment provider, so that the prolonged evaluation and management services are duly paid for.

How to get the insurance provider to reimburse for Spravato?

Here are some things to keep in mind while setting up a Spravato practice. Compared to other practice specialties, Spravato practitioners are required to fulfill the following requirements:

  • Requirements on patient eligibility verifications to receive Spravato

Pre-authorizing the patient to ensure that their insurance reimburse for Spravato is the very first step to take, even before commencing the treatment. Eligibility for benefits varies from one insurance payer to another, and the specific plan under which the patient is enrolled. When you apply for pre-authorization, the insurance payer will check for the evidence that proves the patient’s medical necessity to undergo the treatment and whether the insurance plan covers such types of service under their proposed policies. The patient’s pharmacy benefits should cover for Spravato to receive the drug via buy and bill program.

To prove the medical necessities for Spravato, the patient’s past and current treatment history, physician’s statement on the disease condition, and the supporting medical literature need to be submitted. The prescription, along with the stipulated dosage for Spravato, has to be forwarded too. The criteria and policies for insurance reimbursement for Spravato vary from payer to payer. Sometimes prescriptions are required from specific specialty practitioners and appropriate documents of referral from the primary care physician, without which the eligibility might be denied.spravato-billing-guide-banner-practolytics

In case the patient’s eligibility for receiving the drug is denied after the clinical coverage review, an appeal process can be conducted to revert the adverse decision on behalf of the patient. At Practolytics, we also review claim denials and eligibility denials for your patient and plan an appeal equipped with the right grounds on the existing criteria put forward for Spravato reimbursements. You will also be guided on availing of the buy and bill program in a strategically beneficial manner to match your financial potential.

  • Requirements on the provider to bill for Spravato

To administer and bill for Spravato, your healthcare setting must be certified for Risk Evaluation and Mitigation Strategies. Since the usage of the drug is prone to severe adverse reactions and there are possibilities of its abuse, Spravato is supplied only through authorized channels. The buy and bill programs assign the provider and facilities responsible for prior authorization, storage, handling, inventory, administration of the drug and claim submission to receive Spravato insurance reimburse costs.

The facility has to submit the explanation of benefits received for the patient’s insurance payer to receive Spravato doses for treatment. After a definite period, the patient needs to be re-authorized for the Spravato requirement to obtain the drug for continuing the treatment. The provider should be credentialed with all the necessary licensing to administer Spravato, including drug enforcement administration certifications.

  • Requirements for specific codes to bill for Spravato

There are many things to be considered while billing for Spravato and the codes may vary according to the insurance payer. One of the things to keep in mind is using the appropriate ICD-10-CM codes for diagnosis with the highest level of specificity listed in the order of priority. The date and place of service are also important while coding for Spravato claims to make insurance reimburse for Spravato appropriately for professional services. Assigning codes for Spravato is depends on the dosage prescribed as well because the evaluation and management of an established patient will be conducted by a qualified practitioner based on the dosage of Spravato administered. Coding for the evaluation and management appropriately for the monitoring physician is the main area of focus for Spravato coding.

Depending on the stages of treatment as it progresses through the induction phase and subsequent maintenance phases, codes vary. At Practolytics, we understand how trivial it is to use the most suitable CPT code for the prolonged evaluation and management of the Spravato billing. We can advise you with the right use of code modifiers to tackle the problem.

  • Requirements for processing claims for Spravato

The Spravato claim should be comprehensive and must include the following reports—complete and detailed past medical history and treatment history of the patient, details of all diagnostic tests and evaluations conducted along with the names of providers, documents on referrals for speciality treatment, counselling and patient education, documents on prescriptions and medication charts, inter-departmental communications at the facility, documented details on patient communication and coordination of treatment and follow-ups. Since the claim criteria vary according to the payer, the healthcare provider has to contact the local payer and seek advice on their payment policies and demands furnished on claims.

Practolytics can help you with prior benefit checks and eligibility verifications in up to two days before submitting the claims. We also get your patients pre-authorized for the treatment within 5 days of you prescribing Spravato to them. We submit the claims daily, keeping your patient scheduling in mind so that bills are sent out promptly. If and when claim rejections happen, we intervene at the earliest to make the necessary corrections and do a rebilling for the claim. Practolytics promises you coordinated follow-ups on denied claims with an appeal process backed up by legal support.

Benefits of outsourcing Spravato billing

With the right backup from a smart Spravato biller, you can easily sort out the practical difficulties associated with Spravato insurance reimbursements. An expert Spravato biller can help you in speeding up the process and coordinating the treatment and claim processing with better efficiency. With the right codes and code modifiers, your claims have a better chance of getting accepted without facing denials.

Now, billing and collecting payment for Spravato has been made easier with Practolytics’s collaboration with AdvancedMD and Osmind. With their hi-tech practice management software suite and electronic health record-keeping strategies, every aspect of your practice can be automated and streamlined. Practolytics will cover the installation of the software and implementation of the practice management system at your facility absolutely free of cost. We help you create templates that suit your practice methods and customize the software to aid the specific needs of your practice specialty. Practolytics provides free training and support to you and your clinic staff to make that smooth shift to automating the process with AdvancedMD and Osmind software solutions.

Practolytics  help you resolve all the intricacies related to billing and reimbursement for Spravato. We will give you absolute assistance with pre-authorizations, benefits eligibility, coding nuances and claim processing.  Get in touch with Practolytics today to establish a growing Spravato practice at your us - practolytics

Also Read: Why Do You Need Spravato Billing Solutions?