Pubdate: Sun, 25 Jan 2015
Source: Daily Herald (Arlington Heights, IL)
Copyright: 2015 The Daily Herald Company
Contact:  http://www.dailyherald.com/
Details: http://www.mapinc.org/media/107
Author: Marie Wilson

TREATMENT CENTERS, INSURANCE WORK TO AGREE ON HEROIN CARE

When someone wants treatment to end a heroin addiction, insurance 
shouldn't hold him back.

That's the perspective of addiction treatment professionals who say 
the biggest issue they face with insurance companies is disagreements 
over whether a patient meets the medical criteria for a certain type of care.

Instead of starting all drug rehab patients in residential treatment 
at the highest level of care or in occasional outpatient visits at 
the lowest, treatment providers say the approach should be somewhere 
in the middle.

"The philosophy should really be 'Let's start the client where the 
clinical information indicates they need to start,'" said Tom 
Delegatto, executive director of business development for Gateway 
Foundation Alcohol & Drug Treatment.

He said treatment providers and insurance companies are moving toward 
such an individualized approach, but sometimes the process hits a 
roadblock when the two sides can't agree on which type of program a 
patient needs.

Heroin treatment comes in levels including around-the-clock 
residential care, as well as full-day, partial-day and weekly programs.

A patient must meet different medical standards to qualify for each 
level, said Beth Sack, manager of addiction services at Linden Oaks 
Hospital at Edward in Naperville.

Treatment centers use criteria from the American Society of Addictive 
Medicine to determine how intensive a patient's care should be. Sack 
said providers evaluate a person's substance abuse history, medical 
history, emotional status, readiness to change, recovery living 
environment and support system before calling his or her insurance 
company for approval of care.

A lack of coverage usually doesn't prevent patients from getting some 
treatment, but it can lead to failed attempts to kick a heroin habit 
while only receiving a few hours of help each week, she said.

"Sometimes we might think as a professional that this meets criteria, 
but the insurance company says it doesn't. Sometimes it can be 
frustrating," Sack said. "But getting them in the door at some level 
of care seems to be happening."

Treatment professionals say there have been improvements in coverage 
for heroin recovery, thanks to a state law updated in 2011 that 
requires mental health and substance abuse disorders to be covered 
under the same terms as other medical conditions. Referred to as the 
"parity act," the law decreased issues with insurance companies 
limiting the days of drug treatment a person can receive in a year or 
a lifetime, Sack said.

For example, Blue Cross Blue Shield medical insurance plans generally 
cover residential, full-day, partial-day and weekly outpatient drug 
treatment, and very few plans have any limits on the number of days, 
spokeswoman Mary Ann Schultz said.

"Even if you have unlimited days, insurance still has certain 
criteria you have to meet in order for them to approve those days," Sack said.

Disagreements over whether a person meets criteria for residential 
care still can limit how much help a person can receive from Gateway 
Foundation's treatment center in Aurora, Executive Director Jim Scarpace said.

"Bringing them in the front door doesn't tend to be the major issue; 
the issue is keeping them in treatment for the amount of time they 
would need," Scarpace said.

If a disagreement arises about how long a person should stay in 
residential care, Scarpace said treatment centers can schedule a 
"doc-to-doc" consultation between their doctors and the insurance 
company's to make a final decision. Delegatto said such consultations 
can continue until a patient has completed treatment.

"Hopefully, ultimately at the end, it's what's best for the client," 
Delegatto said.
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MAP posted-by: Jay Bergstrom