Addressing Financial Concerns Around High-Cost Bleeding Disorder Medications

Most bleeding disorder medications are extremely expensive, and this can create a significant financial disincentive for behavioral health facilities to admit individuals who require them—particularly depending on how the individual’s insurance pays for medications.

For example:

• If the person is covered by Medicaid, and the state Medicaid program uses managed care contracts with facilities that involve risk-based payment models, the cost of a single dose of medication could exceed the per diem payment for the person’s entire stay.

• Similar concerns may arise under private insurance plans that use bundled payments, case rates, or global budgets.

These financial dynamics can make facilities reluctant to accept individuals who need high-cost infusions or injections—even when those individuals are otherwise stable and appropriate for care. 

Step 1: Before navigating complex reimbursement pathways, ask whether the facility allows patients to bring in previously prescribed and dispensed medications from home. This is often the simplest and most cost-effective solution.

• Say: “If your facility doesn’t currently have a home medication policy, we’d be happy to share a sample that other programs have used successfully. It can serve as a helpful template to ensure safe, streamlined, and patient-centered care—while also avoiding unnecessary cost concerns.”

Step 2: If home medications are not permitted, the next step is to contact the patient’s insurer to clarify how the medication would be reimbursed.

• Say: “We understand your concerns about the cost of bleeding disorder medications. In some cases, these medications are carved out from risk-based payment arrangements. We’d be happy to contact the insurer or assist in that conversation to clarify reimbursement for this medication.”

• You can use this script to assist in the call with the insurer. After speaking with the insurer, document the conversation to confirm how the bleeding disorder medication will be reimbursed—this ensures clarity for the treatment team and helps prevent delays in admission.

• Sample Home Medication Policy and Procedures Document

• What to include in your communication to the facility:

  - Patient Name:

  - Insurance Plan Name and Type: (e.g., Medicaid Managed Care, Commercial PPO)

  - Payment Model Used: (e.g., fee-for-service, bundled/case rate)

  - Reimbursement Approach for Medication:

  • Is the medication carved out and reimbursed separately?

    • Can the facility bill directly for the medication?

    • Will a specialty pharmacy bill the insurer and ship the product?

  • Any Prior Authorization Requirements: Include specific documents needed and estimated turnaround time.

  • Specialty Pharmacy Information: Include the name, contact, and any requirements.

  • Insurer Contact: Provide a name, phone number, or email for a case manager or billing support contact at the insurer, if available.

• Sample Cover Note to the Facility:

  Dear [Facility Contact Name],

  Following up on our discussion regarding [Patient Name]’s bleeding disorder medication, I’ve confirmed the reimbursement approach with their insurer. Please see the attached summary for details on how the medication will be covered.

  Maintaining [Patient Name]’s established treatment protocol is essential to ensuring medical stability and significantly reduces the risk that their mental health or substance use treatment will be interrupted by bleeding events.

  This information should help clarify that your facility will [not be responsible for the cost / can bill directly / will receive the product via specialty pharmacy], helping ensure that treatment proceeds without disruption.

  Please let us know if you have any questions or if we can support next steps.

  Best regards,
  [Your Name]
  [Your Title / Organization]