In Wisconsin

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. 

If the facility permits the individual to bring in previously prescribed and dispensed bleeding disorder medications from home, it avoids the need for discussions regarding payment for medications. This is often the simplest solution.

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

• Say: “Does your facility have a home medication policy? If so, [insert patient name] has a supply of bleeding disorder medication at home that [insert patient’s name] can bring with them at the time of admission, then payment will not be an issue. If your facility doesn’t currently have a home medication policy, we’d be happy to share a sample policy. 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, you can bill insurance directly for these medications, even if your facility is paid through a risk-based arrangement or gets a “per diem” rate. 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.

Send the following to the facility:

• Medication Reimbursement Approach:Edit this email template to follow up with the facility, and provide information about the expected reimbursement approach for the patient’s BD medications.

• Sample Home Medication Policy and Procedures Document: This document can help a facility define its Home Medication practices in order to allow individuals to bring medications that were prescribed and dispensed to the patient prior to admission into an inpatient or residential mental health or substance use treatment facility.

• Ensure the following is included 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.