What Is Spravato Billing?
Spravato is the only FDA-approved esketamine-based nasal spray for the treatment of treatment-resistant depression (TRD) in adults. According to research, the cost ranges from $5,664 to $8,142 for the first month of treatment. These costs make accurate and timely billing critical.
Spravato billing includes several key components:
- Medication coding: Use special codes, such as S0013 for esketamine nasal spray 1 mg, which differs from the coding for other forms of ketamine.
- Monitoring and observation: billing for patient observation services for a minimum of 2 hours after drug administration.
- REMS compliance: documenting all risk management program requirements.
Spravato billing services require coordination between the clinic, insurer, pharmacy, and manufacturer. It makes the process significantly more complex than standard medical billing.
Why Spravato Billing Requires Specialized Expertise
REMS and Compliance Challenges
The REMS program requires that each healthcare facility be registered in the program, the patient be enrolled in REMS, written patient consent be obtained, and all documentation be retained for insurer audits. An error in any of these elements can result in complete denial of reimbursement.
Spravato is only available through a limited REMS distribution program. It means that every step of the treatment and payment process must be documented and comply with federal standards.
Correct Coding and Documentation
Correct coding is the foundation of successful billing. Special codes are used for esketamine, such as S0013 for a 1 mg dose. Key elements of documentation include:
- Accurate observation time: The observation period must be at least two hours after administration. This period must be documented in the patient’s medical record.
- Documentation of side effects: Clinical trials have shown that 48-61% of patients developed sedation and 0.3-0.4% developed loss of consciousness, and all of these events must be recorded.
- CPT codes for services: Use the correct codes for office visits and monitoring.
Even a single coding error or omission of necessary documentation can result in months of payment delays.
Prior Authorization and Denial Management
Integrating Spravato into practice requires navigating complex billing procedures. And many companies choose to seek help. This results in savings of approximately $12,000 per year through automated REMS compliance verification alone.
Experienced Spravato billing companies help clinics:
- Obtain prior authorization: Work with insurers before treatment begins to ensure coverage is available.
- Manage denials: Analyze reasons for denials and file substantiated appeals with corrected codes and documentation.
- Track insurer policies: Continuously monitor changes in patient requirements and coverage terms.
How We Selected the Top Spravato Billing Companies
We selected companies based on the following criteria:
- Specialized experience in psychiatry and Spravato: understanding the unique requirements of treating treatment-resistant depression.
- REMS certification: full readiness and experience in managing the REMS program.
- Transparent reporting: clear metrics, including claim approval rate, processing time, and percentage of successful appeals.
- Customer reviews: Real reviews from clinics working with companies.
- Scalability: Ability to work with clinics of any size, from single offices to multi-center networks.
- Technology integration: Support for integration with EHR and scheduling systems.
Top 10 Spravato Billing Services Companies in the USA
1. SwiftMDS
SwiftMDS specializes in mental health billing and has deep expertise in Spravato billing services. The company’s team is thoroughly familiar with REMS requirements, works with J-codes, and manages prior authorizations.
SwiftMDS is known for its personalized approach to reporting and transparent pricing. The company provides clients with a personal account manager who knows all the ins and outs of working with each insurer. The platform automatically checks all REMS documents before submitting a claim, which significantly reduces the likelihood of rejection. The company prides itself on its approval rate of over 94% on the first review.
2. Neolytix
Neolytix is a reputable mental health billing company that provides specialized support for Spravato and other psychiatric services. The company has experience working with national clinic networks.
Neolytix stands out for its innovative analytics platform, which tracks all stages of claim processing in real time. They work with over 500 patients receiving Spravato monthly and have established relationships with major insurers. The company is known for its ability to quickly resolve disputed cases, often completing appeals within 30 days. Their Spravato billing company serves practices of all sizes.
3. AdvancedMD Medical Billing
A major player in the market with fully automated processes, integration with major EHR systems, and years of experience working with psychiatric practices across the country. AdvancedMD provides one of the most integrated solutions, allowing clinics to manage all aspects of billing through a single platform.
Their system automatically collects data on medication administration time, observation time, and side effects. It minimizes manual data entry and errors. AdvancedMD supports integration with over 40 different EHR systems, including Epic, Cerner, and Athena. The company has a dedicated Spravato support team that works exclusively with esketamine requirements.
4. Psych Billing Services
Narrowly focused on psychiatry and mental health services, including Spravato, TMS, and ketamine therapy. The company has a deep understanding of the nuances of each treatment. Psych Billing Services works exclusively with psychiatric practices and has the most in-depth understanding of the specific requirements of each treatment.
They are known for their individualized approach, where each clinic is assigned a dedicated team of two to three people who specialize in their practice. The company offers consulting services for implementing Spravato into existing practices. Psych Billing Services has one of the fastest claim processing times among its competitors, averaging 5-7 days for initial review. They also provide monthly analytics reports with detailed breakdowns of claim denials and recommendations for improvement.
5. Medcare MSO
Medcare offers comprehensive revenue management, including Spravato billing company services as part of its psychiatric division. The company serves medium and large practices. Medcare is a full-service medical practice management organization that provides other services in addition to billing, including human resources management, marketing, and facility planning.
Their experience in managing the full spectrum of practice operations makes them an ideal partner for growing psychiatric organizations. Medcare has established relationships with major insurers and Spravato pharmacies. It significantly speeds up the pre-approval process. They offer flexible collaboration models, including full revenue management or consulting services. The company also provides financial advice on optimizing your practice’s revenue model when adding Spravato to your service portfolio, helping you understand what kind of profits you can expect.
6. BillingParadise
The company has a strong technical base, deep experience with J-code services, and REMS compliance verification. It is known for its assistance in complex cases. BillingParadise stands out for its engineering culture and continuously invests in automation and artificial intelligence to improve billing processes.
Their Spravato billing services use advanced algorithms to prevent coding errors before claims are even sent to the insurer. The company has a particular specialization in handling complex multi-insurance situations and coordinating benefits between primary and secondary insurers. BillingParadise is known for its aggressive appeals strategy, with a success rate of over 78% on appealed denied claims.
7. MBILL Health
Works with mental health clinics across the country and is known for accurate coding and effective denial management. Provides detailed reports for each patient. MBILL Health is a medium-sized company that has built its reputation on meticulous attention to detail and personalized service. Each claim is double-checked before submission, minimizing the likelihood of errors.
The company provides its clients with access to a personal account where they can track the status of each claim in real time, including the exact time of submission, initial review, and final decision. MBILL Health has excellent relationships with pharmacy benefit managers (PBMs), which often gives its clients priority review. They also provide free billing strategy consulting to help you optimize your practice and maximize revenue.
8. ClaimCare Medical Billing
Large client network, including psychiatric and neurological practices, with active support for Spravato billing services and experience in managing complex insurer requirements. ClaimCare Medical Billing is one of the largest independent billing providers in the United States, with a client base of over 2,000 practices. Despite its large size, the company has managed to maintain a personal approach to each client thanks to its decentralized structure with regional support teams.
Their Spravato specialists have an average tenure of over 8 years, ensuring deep knowledge and consistency. ClaimCare offers 24/7 support by phone and email, which is especially important for urgent issues. The company is also known for its training program, which helps new clients get up and running quickly.
9. 5 Star Billing Services
Focuses on psychiatry, TMS, and ketamine therapy with a deep understanding of REMS protocols and federal compliance requirements. 5 Star Billing Services earned its name through its commitment to excellence and high customer ratings (average rating of 4.9 out of 5 stars). The company specializes in innovative treatments, including not only Spravato but also TMS, ketamine therapy, and other new psychiatric interventions.
Their REMS specialists undergo continuous training and retraining to stay up to date on all compliance program changes. 5 Star Billing Services provides consulting services for opening new Spravato programs in practices, including assistance with REMS registration and infrastructure preparation. The company is also known for its assistance in recruiting and training the staff needed to serve Spravato patients.
10. PsychPlus Billing
A young but rapidly growing company working with mental health practices and Spravato in several states, providing flexible solutions for growing clinics. PsychPlus Billing was founded in 2019 by a group of former employees of large billing companies who wanted to create a more innovative and customer-focused solution. Despite its youth, the company has quickly gained a reputation for its technological approach and willingness to adapt to the unique needs of each client.
Spravato billing company PsychPlus uses cloud technology and machine learning to improve its processes continuously. The company is known for its rapid implementation of new features and quick response to customer requests. PsychPlus offers a “pay-for-success” pricing model, where a portion of the company’s commission is dependent on the claim approval rate, creating a perfect alignment of interests.
Key Factors to Consider When Choosing a Spravato Billing Partner
When choosing a partner for Spravato billing services, consider the following factors:
- REMS compliance experience: the company’s ability to manage all aspects of the program without errors.
- Proper use of J2315 and CPT codes: demonstration of a clear understanding of all codes related to Spravato.
- Transparent reporting and analytics: the ability to track key metrics in real time.
- Proven history of reducing denials: the company’s statistics on successful reimbursement claims.
- Integration with EHR and scheduling tools: compatibility with your current technology infrastructure.
Why SwiftMDS Is the Right Choice for Spravato Clinics
SwiftMDS is one of the few companies that specializes specifically in Spravato and mental health billing. The company offers personalized support to each client, which is rare in the industry. Transparent reports allow practices to see the exact status of each claim, and flexible rates adapt to the size of the practice. Assistance with pre-authorization and denial management ensures maximum billing success. Contact SwiftMDS for the best solutions for your clinic.
FAQ
How is Spravato billed to insurance?
Spravato is billed using J-code J2315 for esketamine nasal spray, along with CPT codes for administration and monitoring time, usually in combination with evaluation and management codes.
What makes Spravato billing more complex than standard billing?
It is a combination of several factors: REMS documentation requirements, mandatory prior authorization, the complexity of coding combined services (medication + observation), and the specialized nature of the treatment itself.
Can any billing company handle Spravato claims?
Technically, any company can try, but in practice, only Spravato billing companies with specialized experience in psychiatry and a deep understanding of REMS requirements can do so effectively.
What happens if a Spravato claim is denied?
Experienced billers analyze the reason for the denial, correct the codes or documentation, add medical justification, and submit a well-founded appeal, often receiving approval on second review.
Does insurance cover Spravato?
Yes, most major insurers cover Spravato for the treatment of treatment-resistant depression. Still, prior approval and documentation that the patient has not responded to two previous different antidepressants are required.
