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Opioid Drug Treatment Programs: Why Insurance Won’t Pay

Paying for opioid drug treatment programs
Paying for opioid drug treatment programs

The insurance companies just don’t care that people can get help for opioid addiction through opioid drug treatment programs that utilize medications such as methadoneor buprenorphine in conjunction with counseling and other therapies. It doesn’t matter to them that prescription pain killers and heroin account for 61 percent of all overdose deaths in the country.

The ultimate goal of any insurance company is to save money by not paying for treatment of any kind, for anybody. While they can’t get away with this when it comes to routine illnesses such as pneumonia or diabetes, they are still calling the shots when it comes to substance abuse treatment.

Their latest tactic is to threaten us: If they agree to pay for addiction treatment through opioid drug treatment programs, they say, then the drug companies will raise the price of medications such as methadone and buprenorphine so that nobody can afford them. Now, how in the world can they claim that unless (a) they are just desperate to avoid paying for the healthcare that so many Americans need; or (b) they are in collusion with the drug companies to keep the cost of treatment high. How could they possibly know what the drug companies would ever do?

While you try to decide whether the insurance companies are guilty of (a) or (b), we have some things for you to consider. According to Steven Ross Johnson writing for Modern, insurance company executives hope to avoid the rules that expand their obligation to pay for substance abuse treatment. They don’t care that addiction treatment is one of the ten essential healthcare benefits mandated by the Affordable Care Act (ACA). Or, that nearly 20 million Americans are desperately in need of treatment at one of the available opioid drug treatment programs.

This attitude is entirely in step with the panic shown by the insurance industry when it faced President Obama’s implementation of the Affordable Care Act. When the president assured healthcare consumers that nobody would lose their coverage, the companies quickly rewrote their plans so that those in existence became obsolete and people had to choose new plans. The whole thing was a farce to anger and worry people into thinking that the Affordable Care Act would turn their healthcare world upside down.

In reality, the insurance companies were required to rewrite certain points of coverage in order to be grandfathered in under the Affordable Care Act, but they refused to cooperate. While furor over the ACA raged on, only two percent of insured persons had to choose new plans. That two percent affected roughly four million Americans,but over 17 million Americans obtained healthcare insurance under or because of the ACA.

Paying for Opioid Drug Treatment Programs

The insurance companies like to withhold payment for opioid drug treatment programs because they are an easy target. Up until now those types of therapies have made an easy target because of the stigma associated with heroin or opiate drug addiction. The people who suffer from addiction find it difficult to fight for their right to coverage of opioid drug treatment programs.

Opioid drug treatment program providers also find themselves in a quandary with the insurance companies. Methadone and buprenorphine treatment clinics must go through both a contracting and a credentialing process with the insurance companies. Without successfully completing those processes, the insurance companies won’t the treatment.

To further complicate matters, the insurance company that you see named on your health benefits card does not always process payment for opioid drug treatment programs itself. Many farm that coverage out to behavioral health managed care organizations. In those cases, clinics must first contract and credential with the big name health insurance company and then it must contract with the behavioral health insurance company.

And then there are standards set in tiny print that disqualify providers from receiving payment for services. A credentialist at one methadone provider describes one insurance company that covers a certain group of government employees. The company indicates on its website that it pays for substance abuse treatment. However, in the fine print on the policies, it states that the opioid drug treatment program must be certified not by the two biggest certification agencies in the nation—JCAHO or CARF—but by a little-heard-of organization called Kepro. In addition, only those outpatient programs run by an inpatient facility will qualify to receive payment for services provided.

No wonder that so many opioid drug treatment programs find themselves unable to bill insurance companies for methadone or buprenorphine treatment. In many cases they ask clients to pay for services up front. Most people do so if they can, but the average person has little or no knowledge about how to submit their bills to their insurance company. We suggest you call the number on your benefits card and ask the customer service representative for instructions on submitting your claims. You will need a bill from the opioid drug treatment program that includes a diagnosis code and a procedure code.

Should My Insurance Cover Substance Abuse Treatment?

Everybody cites the Mental Health Parity and Addiction Treatment Act of 2008, but there are some restrictions that may affect your coverage.

  • Health plans issued by employers with fewer than 51 people do not have to comply with the Act.
  • State and local health insurance plans can opt out of complying with the Act.
  • The Act does not provide for a predefined definition of substance use disorder benefits.
  • Employers who self-insure can opt out of providing substance abuse treatment coverage.
  • In some cases when a plan can opt out of complying with the federal Act, there may be a state law that will require them to pay for coverage.

If you have questions or continued difficulty with your health insurance provider, tell them calmly that you plan to take your issues to your state’s Department of Insurance. You may find the insurance company representatives will be more willing to help you if they know you are going that route.

In the meantime, don’t give up on obtaining help at a local opioid drug treatment program. Most of them will work with you to set up a payment plan. And most state Medicaid plans provide coverage for treatment. Call today to find out how you can get help.

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