by Justin Mckibben | Mar 19, 2019 | Addiction Treatment, Depression, Detox, Inpatient Treatment, Mental Health, News, Outpatient Treatment
Discrimination Through Denial of Coverage
Health insurance is probably going to be one of the great debates of this period in American history. There is already plenty of contention about how to properly provide coverage for those who need it. Some claim the changes made in the last decade have gone too far. Others argue it has not gone nearly far enough. Healthcare reform is a hot button issue in our world today. Needless to say, a big part of this conversation has to do with parity coverage for mental health. Now a new landmark court ruling is going to make a monumental difference for mental health and addiction treatment insurance coverage.
Simply put, the largest behavioral health care company in America has been denying coverage to some of its most vulnerable members to save money. And now, a federal court decision may put more of a spotlight on insurance companies.
Wit v. United Behavioral Health
The case was brought in front of a federal court in Northern California against United Behavioral Health (UBH). UBH is a company that manages behavioral health services for UnitedHealthcare and other health insurers. The court found that UBH denied claims of tens of thousands of people seeking mental health and substance use disorder treatment. The company was using defective medical review criteria in order to reject claims.
In Wit v. UBH, over 50,000 individuals were reportedly denied coverage based on the flawed review criteria. 11 plaintiffs sued UBH on the behalf of these victims. One victim, in particular, is Natasha Wit. Natasha had been seeking treatment for several chronic conditions, including:
Wit was repeatedly denied coverage for her treatment, despite the fact she did have healthcare benefits that should have offered coverage. Her family ended up paying out nearly $30,000 for treatment. And they are just one of the thousands of families to face the same discrimination.
Looking at the Marks Against UBH
According to recent reports, United Behavioral Health has been failing its members in more ways than one.
Federal courts determined that UBH developed internal guidelines that were “unreasonable and an abuse of discretion” and “infected” by financial incentives designed to restrict access to care for those who should qualify for coverage. Essentially, UBH was manipulating internal guidelines to avoid providing coverage that members had every right to under the law.
For many of those struggling with substance use disorder, defective criteria for coverage can equate to a death sentence. When looking over the requirements set by UBH, it is no wonder why the courts say they are illegitimate.
Firstly, their medical-necessity criteria fail to provide coverage to those chronic and comorbid conditions. Generally accepted standards of care state these conditions should be effectively treated, even when those conditions:
- Persist
- Respond slowly to treatment
- Require extended or intensive levels of care
However, UBH set guidelines that only approve coverage for what they labeled “acute” episodes or crises. For example, only individuals who were actively suicidal or suffering from severe withdrawal could be considered for coverage.
In other words, for someone who struggled with substance use disorder or mental illness, you had to be knocking on death’s door to get a chance at treatment. The court found that these guidelines were not acceptable.
Furthermore, UBH fails to use national evidence-based guidelines for covering different levels of care for mental health and substance abuse treatment, such as:
These are guidelines that have been developed by clinical specialty nonprofit organizations.
Additionally, UBH’s guidelines improperly required reducing the level of care, even if the providers who were treating them recommended maintaining a higher level of care. So patients would be removed from more intensive residential treatment programs and pushing into some form of outpatient therapy, even if the specialists argued that they were not ready.
This is a big deal. Most recovery advocates and healthcare providers agree that insurance companies should not be the ones telling treatment providers how to care for their patients.
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State Mandated Guidelines
Furthermore, some states have mandated specific guidelines for evaluating the medical necessity for behavioral health services. UBH was also found to have violated these requirements for reviewing substance use disorder claims as well.
The case against United Behavioral Health was filed under the Employee Retirement Income Security Act of 1974 (ERISA). This is a federal mandate that governs group health insurance policies through private employers. More specifically, ERISA requires insurance plan administrators to function in a fiduciary capacity when overseeing employee benefit plans. This includes coverage for mental health and substance use disorder treatment.
In Wit v. UBH, the court determined that UBH was in breach of its fiduciary duties by developing and employing faulty medical necessity criteria for behavioral health services. Therefore, the court alleges that UBH is in violation of its obligations under this federal law.
What Does this Mean for Addiction Treatment Insurance Coverage?
This case is exposing insurers for refusing care to people at serious risk of death by overdose or suicide. It is important to remember that UBH is not the only insurance provider trying to find ways around federal and state coverage guidelines. Given the nature of these violations, advocates believe that regulators should immediately start examining the market conduct of all healthcare plans across the country.
Judge Joseph C. Spero in Wit v. UBH also points out that the company was circumventing the Mental Health Parity and Addiction Equity Act of 2008, also known as the Federal Parity Law.
Parity law actually requires insurers to cover illnesses of the brain, such as depression or addiction, the same as illnesses of the body, such as diabetes or cancer. In his ruling on Wit v. United Behavioral Health, Judge Spero highlights an abundance of evidence that guidelines created by the UBH were designed to diminish the impact of the 2008 Parity Act in order to keep benefit costs down. In other words, it is clear that the company was actively trying to work around federal law in order to avoid providing coverage to people with mental illnesses and addictions.
For those in the mental health and addiction communities, this brings new awareness to the discriminatory practices of treating mental health conditions differently than physical conditions. The new hope is that insurance providers will understand the consequences of discrimination against those who need help. With so much going on in healthcare, the Federal Parity Law must be protected.
Far too many people suffering from mental health and substance use disorders never get the help that they need. The last thing we need in a country devastated by an opioid crisis and rising overdose death rates is to create more roadblocks to treatment resources.
Palm Healthcare Company believes that if our country is ever going to overcome the damage of the opioid epidemic, we have to offer more comprehensive treatment options to those who still suffer. Insurance companies should not be keeping people from the care they deserve. Prevention is important, but we also believe in taking care of those who are already in the grips of substance use disorder by offering compassionate and effective care. If you or someone you love is struggling, please call toll-free now. We want to help.
CALL NOW 1-888-922-5398
by Justin Mckibben | Oct 24, 2017 | Addiction Stigma, Addiction Treatment, Drug Policy, Inpatient Treatment, Mental Health, News, Prescription Drugs
If that headline seems kind of confusing, don’t worry, it should. Technically insurance companies are already required by law to provide the same coverage for substance abuse and mental health that they do for other health conditions… and therein lies the issue.
Back in August the White House Opioid Commission, established by President Trump and led by New Jersey Governor Chris Christie, made several recommendations to the current administration about how to address the current drug crisis as it damages communities across the country. One of those recommendations was to declare a national emergency, while others had to do with options for prevention and education.
In the aftermath of ex-DEA agent Joe Rannazzisi’s eye-opening interview exposing the shady connections between Congress and Big Pharma companies, many have been looking closely at how government officials and multi-billion dollar empires helped create the opioid epidemic. Now the White House’s Opioid Commission is putting a focus on how health insurance companies and the flaws in their policies have contributed to the intensifying addiction crisis.
So with the opioid commission saying they will call-out insurers and make demands on coverage for addiction treatment, will more people have access to help?
Restricted Addiction Treatment
One of the biggest issues the opioid commission seems to have with insurance companies is that frequently their policies only cover one type of addiction treatment and not others. It seems insurance companies are convinced that with a complex and extremely personal issue like substance use disorder or mental health conditions, there is a one-size-fits-all answer. Sadly, most advocates can tell you this isn’t the case.
Something else especially frustrating is that laws already exist to prevent insurers from treating addiction treatment different than any other health issue. Chris Christie himself said,
“Why are we still not seeing addiction services covered, and mental health services covered as broadly as every other type of disease?”
“And what do we need to do to make sure that the law is enforced and followed?”
The Mental Health Parity and Addiction Equity Act of 2008 requires health insurers to treat mental health and substance abuse disorders the same as any other disease. It means they should provide health care coverage for these conditions without additional limits, co-pays or deductibles. If companies add on additional requirements, it creates even more barriers between the suffering individual and treatment. Sadly, not every insurance company thinks it has to play by the rules.
A task force convened by President Barack Obama last year reported that numerous insurance companies still place a number of limits on addiction coverage, like more strict pre-authorization requirements. The insurance companies claim that their policies are only part of a complex problem, insisting that the issue also has to do with shortages of doctors and poor medical training from healthcare providers in the field of addiction treatment.
However, the simple fact that insurance companies are still trying to push back against supporting addiction treatment has the opioid commission ready to address the inconsistencies that are making it even harder for people who need help to get the help they deserve.
Holding Insurance Companies Accountable
The opioid commission is not holding back when it comes to trying to make insurance companies contribute to solutions since they helped contribute to the problem. The New Jersey Governor warned health insurance companies to be prepared for a final report that will “place new demands” on health insurance policies.
Christie and the opioid commission seem to be playing offense, saying Big Pharma drug companies and health insurers profit while allowing an epidemic of addiction to continue, but these new demands will hopefully change all that. Christie added,
“I’m a capitalist. I want everybody to make profits. I think it’s great. But we can’t any longer go about addressing this problem this way,”
“I hope you’re prepared to accept the challenge, because we know if it hasn’t gotten into your own house yet, it could, and then all the sudden your perspective on this problem could become markedly different.”
Not only is there more pressure on insurance companies when it comes to treatment options in their policies, but with how they handle medications in the first place.
Health insurance providers are also under a greater deal of scrutiny for policies that sometimes favor powerful and addictive painkillers over less addictive, and more expensive, variations. So not only are they limiting the options when it comes to getting treatment for substance abuse, but they are limiting coverage of medications to more addictive drugs to save money.
Insurance providers did show up to testify at the commission to help create a more comprehensive view of the issue. Involved were executives from some of the nation’s largest insurance companies:
- Aetna
- Anthem
- Blue Cross Blue Shield
- Cigna
- Harvard Pilgrim Health Care
- Kaiser Permanente
- UnitedHealth Group
- UPMC Health Plan
Representative Elijah Cummings, the ranking member of the House Oversight Committee, also has questions for many of those same companies. Some of these inquiries stem from a report by The New York Times last month stating insurance companies “erected more hurdles to approving addiction treatments than for the addictive substances themselves.”
Cummings wrote letters to seven of the companies which state,
“This is not a hypothetical problem. The over-prescription of opioids leads to addiction and death.”
The White House’s opioid commission has also spoken with leaders in the pharmaceutical industry. All this shows that the opioid commission is not only worried about exploring our options for fixing the issue but also in examining all the elements that helped cause the opioid epidemic in America. Christie says the final report to President Trump will include sweeping recommendations but will also be “extraordinarily instructive in terms of how we got here, which is an important thing for this commission to acknowledge.”
The commission will hold its last meeting November 1st before delivering its final report to the President. Only time will tell what demands this report plans to place on insurance companies to provide more coverage for addiction treatment services.
Will Insurance Companies Change?
The big question becomes how will this impact the services offered by insurance companies. Will the opioid commission’s suggestions help shape new policies, or will some insurance companies continue to ignore the parity laws put in place to make sure they do not discriminate against the treatment of substance abuse?
Will these changes allow for the coverage of different innovative and holistic treatment options, or will the change only support programs that depend on maintenance drugs like methadone or Suboxone?
Hopefully, the new demands being put on insurance companies will help to support mental health and substance abuse parity. When it comes to addressing addiction in America, we need every resource we can get in order to move forward with overcoming the opioid epidemic. With more officials taking a closer look at every aspect of the issue, perhaps we can get a more effective strategy for addressing the problem.
With so many people struggling with opioids and other drugs across the country, comprehensive and effective treatment is essential to making any real progress. For decades Palm Healthcare Company facilities have been providing holistic addiction treatment options that help create lasting change. If you or someone you love is struggling with substance abuse or addiction, please call toll free now.
CALL NOW 1-888-922-5398
