Medically Necessary

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 for as many people as possible. More addiction treatment is now covered by more insurance plans. Ideally, there is a mutual goal. It’s important both for patients to use their health insurance, and for hospital centers receive adequate reimbursement from these insurance plans. What is medically necessary will determine the level of care covered by insurance.

Past Legislation

Much of this trend extends back to healthcare parity legislation over the past 20. Parity means that behavioral health conditions such as depression or alcoholism. They are to be treated ‘on par’ with other chronic medical conditions, such as diabetes or heart disease. Insurance carriers are required to offer similar benefit coverage for these conditions rather than denying coverage.

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. 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.

Medical Necessity

Healthcare entities have a legal obligation to offer coverage for addictive disorders. They also make complex decisions about the intensity and level of such coverage. This is their process of determining ‘medical necessity.’ Some of this about rationing healthcare dollars and auditing the delivered treatment of healthcare centers. In theory, the insurance company wants the individual consumer to reach recovery and stability in the most cost-effective and efficient way possible.

For instance, a person may be in our CeDAR intensive residential program for 11 days out of a 30-day full course of care. That person’s insurance company may have initially only approved 12 days of medically necessary residential treatment. This creates a tense situation. The insurance company 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 recommending steps for after treatment and outside referrals.

Determining Coverage

Insurance companies have a set of criteria used to 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 residential services benefits 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 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 medically necessary recommendations to the patient. This process has the potential for extending insurance benefits for the person, but sometimes our hope for further insurance coverage gets rejected. They offer benefits for a lesser level of care rather than continued residential treatment.

Who Makes Recommendations

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. They avoid any language saying 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 followed by 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 recommend the person continue with this level of care even if it may mean accruing out-of-pocket costs.

Common Issues and Concerns

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. The change also needs to occur on a national health level.

Insurance companies often authorize residential treatment in small ‘bursts’ such as 5-7 day increments. This can be difficult and even anxiety-provoking for a patient who may not fully know what their trajectory will be. For these individuals, we work hard to make sure that they have an organized living situation. We structure some viable options for step-down care should the insurance company deny any further supported days in residential treatment.
Some insurance physicians who conduct the peer-to-peer reviews of cases seem to have a limited understanding of advanced addiction recovery topics like medication-assisted treatment. We often find that they are viewing someone’s health case more through the lens of classical inpatient psychiatry management (i.e. basic safety and mood destabilization). They know less about addiction recovery and relapse prevention. We have experienced some highly complex cases in which insurance denial of residential care seemed medically necessary from our clinical expertise. There may not be any great options for us in this area. We often recommend to families that they submit an appeal to their insurance company.
We understand that addiction is an ambivalent disease. Change is hard and complex, and many of our patients switch back and forth between change and status quo. For these individuals, insurance rejection of care can be especially dangerous because it may reinforce distorted beliefs they are not all that sick. The best way to address this is over the long-term and keeping someone engaged in the CeDAR continuum of care. Motivational and acceptance approaches to recovery require time.

Understanding Your Insurance

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.