SOCIOLOGY AND PUBLIC HEALTH
Over the past two years, CeDAR has expanded its capabilities and personnel to work with insurance carriers. This advancement aligns with our goals of expanding access to quality addiction treatment to as many people as possible. More addiction treatment is now covered by more insurance plans, hence there is a mutual goal of patients being able to use their health insurance and hospital centers receiving adequate benefit through the insurance plans.
Much of this trend extends back to legislation over the past 20 years in America, focusing on healthcare parity. Parity means that behavioral health conditions such as depression or alcoholism are treated ‘on par’ with other chronic medical conditions, such as diabetes or heart disease. In this way, insurance carriers are required to offer some benefit coverage for these conditions rather than neglecting some over others.
In recent years, there have even been struggles within behavioral health centers and their views on parity. It was common for clinics to offer treatment for depression or schizophrenia, but reject treatment for opioid addiction based on the insurance benefits. Some of this still exists, and this is where CeDAR and UCHealth continue to advance our services. Our ultimate goal is to offer as many services and levels of care to as many people as possible.
While healthcare entities have a legal obligation to offer coverage for the addictive disorders we encounter, they make complex decisions about the intensity and level of such coverage. They call this process of determining ‘medical necessity.’ Some of this process is based on rationing healthcare dollars and auditing the delivered treatment of healthcare centers. In theory, the insurance company has an interest in the individual consumer reaching recovery and stability in the most cost-effective and efficient way possible.
For instance, a person may be treated in our CeDAR intensive residential program for 11 days and still have an estimated 19 days left for the full course of care. That person’s insurance company may have initially approved 12 days of treatment, hence they will review the medical chart and ask certain questions about the person’s progress and plan. These questions include such things as suicidal risk, depressive symptoms, substance withdrawal markers, or the presence of cravings to relapse. They also want to know that the clinical team is thinking about steps after treatment and referrals.
The insurance companies have a set of criteria by which they determine whether or not extending the person’s residential stay is medically necessary. If they feel that the person is medically appropriate for a less intensive level of care (such as an Intensive Outpatient Program), they may deny further benefits for residential services and advise the person to seek the next step down.
Sometimes, our team at CeDAR will discuss the person’s treatment case on the phone with an outside doctor who is employed by the insurance company. This is called a “Peer-to-Peer Review.” That doctor has some additional questions about the patient’s case. We will discuss in greater detail our rationale for recommendations for that individual. This process has the potential for extending insurance benefits for the person, but sometimes our hope for further insurance coverage gets rejected and the person gets offered benefits for a lesser level of care rather than continued residential treatment.
It is important to know that the final healthcare recommendations for any individual come from the treating physician and the healthcare team at CeDAR. Insurance companies are very careful to acknowledge this and avoid any language which says they are recommending anything in terms of health decisions. We find some conflict in this process, as many people are very bound to the limitations of their health insurance.
Our team works to acknowledge as many variables in a case as possible, and that includes financial areas. Many people are able to fully recover after some period of residential care and then a transition through the lower continuum of recovery services. Alternatively, there are some instances in which we feel the insurance rejection of residential treatment is incorrect. We are then recommending the person continue with this level of care even if it may mean accruing out-of-pocket costs.
What are some of the most common problems we experience in this medical utilization process? Below we’ll list a few examples. We are continually working to improve these issues, but change may also need to occur on a national health level.
Today’s healthcare system is exceedingly complex. Patients are expected to understand insurance benefits, medical necessity and available resources for quality care. One of the greatest predictors of someone’s overall health is the ability of that person to effectively navigate the healthcare system. Fortunately, our insurance review team at CeDAR is exceptionally strong and competent. If you or a family member are receiving care through UCHealth and CeDAR, please outreach them to clarify any questions you may have about the process.