Insurance companies pushed to cover addiction treatment [Cape Cod Times, Hyannis, Mass.]

April 08--SANDWICH -- Trudy Avery's life changed completely when her son became addicted to opiates while at Sandwich High School.

In four years, the mother of four grown sons has joined a host of volunteer committees related to addiction and spoken on Beacon Hill. She went from a job fundraising at Massachusetts Maritime Academy to fundraising for Caron Treatment Centers, which operates in several states.

But first, Avery learned how to fight insurance companies.

Blue Cross Blue Shield of Massachusetts didn't know what it was up against when it refused to cover her son Corey's extended treatment for opiate addiction at the Florida Center for Recovery in 2008.

Corey began abusing oxycodone while in high school.

At 18, he sought treatment for the first time at Gosnold on Cape Cod's detox hospital in Falmouth. After a five-day stay, paid for by the family's Blue Cross Blue Shield policy, he "begged to be transferred to a 30-day program," Avery said.

But insurance wouldn't cover it.

As Avery soon learned, the insurance policy stated it would allow up to "60 inpatient days per member per calender year in a mental hospital or substance abuse facility."

But the stays had to be pre-approved by the insurance company. And the approval came down to whether the insurance company deemed the treatment "medically necessary," Avery said.

Three years after Corey's first detox treatment, when he was 21, he overdosed while living with his grandmother in Connecticut in September 2008.

"It was an absolute heartbreak to our family, but I can now look back at it as our blessing in disguise," Trudy Avery said. "Corey now had the 'medical necessity' for the addiction treatment he had been seeking all those long years."

The insurance company approved a 14-day stay at the Florida Center for Recovery in Fort Pierce.

Corey moved next to outpatient treatment at the Transformations Treatment Center in Delray Beach.

But Blue Cross Blue Shield denied his $23,000 claim for the outpatient treatment, saying his benefits were used up.

Avery didn't give up.

"My son had a medical overdose and was entitled to those 60 days stated in our contract," she said.

Avery appealed the denial. She contacted Massachusetts Attorney General Martha Coakley, and in the meantime, told her story publicly to the state's former OxyContin and Heroin Commission, a group formed to hear testimony from those affected by opiate addiction and to craft legislation to fight opiate abuse.

In September 2009, she testified at the Statehouse.

After she spoke, state Sen. Steven Tolman, D-Brighton, who was then chairman of the heroin commission, called a meeting with the president of Blue Cross Blue Shield of Massachusetts and Avery in his office.

The meeting never happened because "lo and behold, I got paid in full," Avery said.

"I think they were afraid of the publicity," she said. "I think the insurance companies hope that the majority of people will accept their 'no' without question, or just give up."

A Blue Cross Blue Shield representative would not talk about the Avery case because of patient privacy laws.

Families spending thousands

The Avery family is hardly alone in its fight to have addiction treatment covered by private health insurance.

In 2011, only 64 percent of substance abuse treatment facilities accepted private health insurance, according to the federally funded Substance Abuse and Mental Health Services Administration.

Private insurance payments were accepted at 85 percent of facilities with a primary focus on mental health services, the report found. At facilities that treated mainly substance abuse, only 56 percent accepted private insurance.

For members of Parents Supporting Parents, the Cape self-help group for parents of addicts, this isn't news.

Many parents have paid $20,000 to $60,000 at a time to put their children into long-term treatment or reputable inpatient facilities that don't accept insurance at all.

When parents ask how they can pay for addiction treatment, Mashpee mother Lisa Murphy, who founded the support group, says, "Take your children off your private plan, and tell them to go on MassHealth."

It's true that MassHealth -- publicly funded insurance -- pays for a lot of addiction programs. But that adds a burden to taxpayers and the treatment centers since MassHealth payments cover only 70 percent of the cost of services, said Gosnold on Cape Cod President and CEO Raymond Tamasi.

Gosnold tries to have a mix of patients paying privately, on MassHealth or receiving free care.

"We have to pay close attention to our 'pair mix,'" Tamasi said.

With the wave of young opiate addicts that followed the U.S. Food and Drug Administration's approval of OxyContin in 1995, Tamasi hears the Avery story quite often.

Families read "60 days" in their policies, he said. But they soon discover the insurance company won't approve that much treatment, particularly for someone seeking help for the first time.

"It's a fail-first policy," Tamasi said. "You have to fail at a lesser level of care first ... It's the worst part of this field."

Laws no match for insurance companies

Laws in 43 states require commercial group health insurance plans to provide some level of treatment for alcohol or other drug addiction, according to Deb Beck, president of Drug and Alcohol Services Providers of Pennsylvania and a consultant with the National Alliance for Model State Drug Laws, which was created and funded by a bipartisan act of Congress.

But many insurance companies and managed-care firms continue to work to find ways around the laws, she said.

"This is the hidden part of the war on drugs," Beck said. "Everyone says, 'We want to treat addiction.' But the insurance companies make it very difficult to access the treatment required by law."

In 2008, Congress passed the Mental Health Parity and Addiction Equity Act. It requires group insurance plans that already offer mental health and substance abuse treatment to offer the coverage at the same level as other medical benefits.

But the equity act hasn't improved coverage, Tamasi said.

In theory, the bill was a victory for treatment because it placed the disease of addiction on the same plane with physical ailments, he said.

"But the guidelines on how it is implemented and interpreted is a miasma of confusion," he said. "And we still don't have full implementation."

Tamasi has seen insurance coverage become more selective about what it approves and more restrictive since the 1970s, he said.

Twenty years ago insurance typically approved a 28-day inpatient treatment stay. Now it's much less, often just a week.

Gosnold has five full-time employees whose sole job is to call insurance companies arguing for a few more days of treatment for patients, he said.

As Avery learned last year, the equity act wasn't exactly the answer to her prayers.

After three years of sobriety, Corey relapsed briefly in February 2012 with prescription stimulants and alcohol while starting his new recovery-focused business called sobernation.com.

Corey, 25 and still on his family's insurance plan, got himself back into a treatment program within two months of his relapse, he said.

Avery called Blue Cross Blue Shield, seeking coverage again.

This time, the insurance policy couldn't put an annual time limit on the treatment because of the new requirements of the equity act, she said.

But everything else about fighting for Corey's treatment was familiar.

Eventually the insurance company paid for about one month of inpatient treatment, Avery said. That treatment was approved in five- to seven-day increments.

"They still strive to give the least treatment necessary," she said.

As before, the treatments had to be deemed "medically necessary" by the insurance company, she said.

"I think the parity bill is helping, but not much," Avery said.

Holding companies accountable

Dr. Jan Cook, a medical director at Blue Cross Blue Shield, said the definition of "medical necessity" is broad. She said the actual degree of treatment that gets approved is determined on a case-by-case basis after a "conversation" between the patient's doctor and the insurance company's medical staff.

The insurance company, however, does not have to agree with the doctor or treatment specialist.

And the appeals process is incredibly time-consuming and costly, Tamasi said.

Blue Cross Blue Shield receives more claims for substance abuse treatment now, but not because of the equity act, said Sharon Torgerson, the company's Massachusetts director of public relations.

Inpatient substance abuse treatment for Blue Cross Blue Shield clients rose by 7.6 percent in 2012 and by 5 percent in 2011 because of a rise in addiction nationally and in Massachusetts, she said.

As Beck says, laws alone don't force change, unless those laws also come with enforcement.

"States need to move forward to monitor and measure compliance by the insurance companies," Beck said. "Right now, accountability tools available to the states are not being used, don't exist or are too complicated for the average person to decipher."

Beck said her home state of Pennsylvania has done a lot of work on ways to hold insurance companies accountable.

In 2009, Pennsylvania'sSupreme Court upheld one of the strongest laws in the nation that requires insurance companies to cover addiction treatment. The law states that a managed-care plan does not have the authority to overrule a referral by a doctor or psychologist.

Beck said Pennsylvania's addiction treatment law has been on the books since 1986. But when managed care came to the state in the early 1990s, many people were "unable to access the treatment required under law," she said.

In 2004, the insurance companies mounted a legal challenge to Pennsylvania's addiction treatment law that went all the way up to the Pennsylvania Supreme Court. Five years later, the court upheld the state's enforcement efforts, Beck said.

"And Pennsylvanians' access to lifesaving addiction treatment required under law improved dramatically," Beck said.

Before Tolman resigned from the Massachusetts Senate in 2011, he sponsored a bill modeled on Pennsylvania's that would allow the doctor, not the insurance company, to determine the type and duration of treatment.

The bill -- House 936 an Act to Further Define Adverse Determinations by Insurers -- was refiled this year by state Rep. Kay Khan, D-Newton.

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