Treatment centers, insurance work to agree on heroin care

Posted1/25/2015 7:30 AM

When someone wants treatment to end a heroin addiction, insurance shouldn't hold him back.

That's the perspective of addiction treatment professionals who say the biggest issue they face with insurance companies is disagreements over whether a patient meets the medical criteria for a certain type of care.


Instead of starting all drug rehab patients in residential treatment at the highest level of care or in occasional outpatient visits at the lowest, treatment providers say the approach should be somewhere in the middle.

"The philosophy should really be 'Let's start the client where the clinical information indicates they need to start,'" said Tom Delegatto, executive director of business development for Gateway Foundation Alcohol & Drug Treatment.

He said treatment providers and insurance companies are moving toward such an individualized approach, but sometimes the process hits a roadblock when the two sides can't agree on which type of program a patient needs.

Heroin treatment comes in levels including around-the-clock residential care, as well as full-day, partial-day and weekly programs.

A patient must meet different medical standards to qualify for each level, said Beth Sack, manager of addiction services at Linden Oaks Hospital at Edward in Naperville.

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Treatment centers use criteria from the American Society of Addictive Medicine to determine how intensive a patient's care should be. Sack said providers evaluate a person's substance abuse history, medical history, emotional status, readiness to change, recovery living environment and support system before calling his or her insurance company for approval of care.

A lack of coverage usually doesn't prevent patients from getting some treatment, but it can lead to failed attempts to kick a heroin habit while only receiving a few hours of help each week, she said.

"Sometimes we might think as a professional that this meets criteria, but the insurance company says it doesn't. Sometimes it can be frustrating," Sack said. "But getting them in the door at some level of care seems to be happening."

Treatment professionals say there have been improvements in coverage for heroin recovery, thanks to a state law updated in 2011 that requires mental health and substance abuse disorders to be covered under the same terms as other medical conditions. Referred to as the "parity act," the law decreased issues with insurance companies limiting the days of drug treatment a person can receive in a year or a lifetime, Sack said.


For example, Blue Cross Blue Shield medical insurance plans generally cover residential, full-day, partial-day and weekly outpatient drug treatment, and very few plans have any limits on the number of days, spokeswoman Mary Ann Schultz said.

"Even if you have unlimited days, insurance still has certain criteria you have to meet in order for them to approve those days," Sack said.

Disagreements over whether a person meets criteria for residential care still can limit how much help a person can receive from Gateway Foundation's treatment center in Aurora, Executive Director Jim Scarpace said.

"Bringing them in the front door doesn't tend to be the major issue; the issue is keeping them in treatment for the amount of time they would need," Scarpace said.

If a disagreement arises about how long a person should stay in residential care, Scarpace said treatment centers can schedule a "doc-to-doc" consultation between their doctors and the insurance company's to make a final decision. Delegatto said such consultations can continue until a patient has completed treatment.

"Hopefully, ultimately at the end, it's what's best for the client," Delegatto said.

• This article is part of our "Heroin in the Suburbs: Through Their Eyes" series. For more see

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