State to examine how insurers handle claims for substance abuse treatment

Nov. 26--CONCORD -- New Hampshire insurance officials have begun a "targeted examination" of how insurance companies authorize, deny and review claims for substance abuse treatment, the state Insurance Department announced Wednesday.

The announcement comes as officials in and out of New Hampshire raise questions about whether insurance companies are following federal law, which requires carriers to handle mental health and physical health claims on an equal footing.

This year, New York State has forced five insurers to comply with the federal parity law and is imposing fines for not doing so.

One Manchester-area treatment center said it believes insurance companies are treating substance abuse claims differently.

"We've had it mostly from Medicaid, but we've seen it with private insurance as well," said Stephanie Bergeron, spokesman for Serenity Place, a treatment facility in Manchester that sees 1,500 clients a year. Insurers have denied coverage enough times that the organization has started to track the denials and seek preauthorization, she said.

"A lot of our clients are coming to us, we're treating them and they're completely under the impression they're covered," Bergeron said.

The Insurance Department said it will also assess whether a patient's access to substance abuse treatment providers is adequate, the carrier's network of substance abuse treatment facilities, and the carrier's system for handling denials of substance abuse claims.

"Under New Hampshire and federal law, insurance policies that cover treatment for mental health conditions -- including substance use disorder and addiction -- must do so in the same manner and to the same degree as they cover conditions relating to physical health," Insurance Commissioner Roger Sevigny said in a statement.

Carriers found to be in violation can face a number of repercussions: an order to correct the violation, monetary penalties and even an order to cease operations in the state.

The Insurance Department said it is focusing on a narrow time period -- the nine months ending Sept. 30, 2015 -- meaning a preliminary report should be available as early as January. That would coincide with expected attempts in the state Legislature to address opioid and heroin addiction issues.

Initiatives are now under review by a special legislative task force that began its work this week.

Before January 2014, New Hampshire insurers in the individual market were not required to provide mental health services. But the Obamacare law required that policies sold on the exchange include mental health and substance abuse treatment. "What the Insurance Department is doing is an important step forward," said Tym Rourke, the chairman of the Governor's Commission on Alcohol and Drug Abuse Prevention, Treatment, and Recovery. "This is a good moment to take a pause and make sure the foundation of what we're providing is parity compliant."

He said insurance companies will say a treatment is not medically necessary when denying claims. But often it takes place under questionable circumstances.

For example, Rouke said he heard about a patient who was denied treatment services for alcohol addiction after his discharge from a hospital for liver surgery. The reason: He had not been drinking while in the hospital.

"There's this term 'medical necessity' where insurance companies can deny because they feel you don't meet the medical need for care," Rourke said.

Consumers whose claims are denied have the ability to file appeals. An appeal can take place internally within the insurance company and externally with a panel of medical experts certified by the Insurance Department to consider appeals of claim denials.

Contact the Insurance Department with questions regarding insurance coverage at 1-800-852-3416 or 271-1406, or email [email protected].

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