Oklahoma addiction treatment facilities report trouble with insurance coverage

Oklahoma City — When patients check into Eagle Ridge Institute, CEO Michael Hanes knows his staff may have as little as 10 days to try to change a life's downward trajectory.

Eagle Ridge, in Oklahoma City, treats pregnant women and mothers with addictions. Many have extensive histories of trauma that contribute to their drug use, Hanes said, but insurance companies sometimes only authorize a few days of inpatient treatment — assuming they agree to it at all. In those cases, the providers don't dig deeply into a patients' histories, because they won't have the time to help patients process the memories that come up, he said.

Patients' brains need to begin to heal from the effects of drugs before they can work with providers to address any mental health conditions or socioeconomic problems they face, Hanes said. The process can take 90 days or longer, he said, and not all insurers are willing to allow that much time.

Insurers “are unwilling to treat it as a chronic condition,” he said. “They see it like, you get an infection, you get an antibiotic and you're cured.”

Federal law requires parity in insurance benefits for mental health and addiction treatment, meaning companies can't set tougher restrictions for those types of care than for physical health services. For example, insurers can't set limits on the number of times a patient can visit a mental health provider, if they don't have the same limits for medical providers. They also aren't allowed to charge patients higher out-of-pocket costs for behavioral health care, which includes both mental health and addiction.

In practice, however, it may not always work out that way. Some insurers still have higher out-of-pocket costs for substance use disorder treatment than for medical care, Hanes said — which would appear to be a clear parity violation. Other disparities, however, are harder to pin down.

A report by Milliman, a consulting firm, found that in 2015 primary care providers in Oklahoma were paid about 18 percent more than behavioral health providers. The gap narrowed when the analysts compared two specific services that both types of providers could offer, but primary care providers still earned about 8 percent more. The gap was wider when behavioral health providers were compared to specialists. Disparities were even larger in many other states.

Lower rates could also contribute to other disparities, the report suggested, because providers tend not to join plans that don't offer competitive rates. In Oklahoma, people who needed inpatient behavioral care were four times more likely to have to go out-of-network than people who needed hospital treatment for a medical issue in 2015. Insurance companies set up networks of providers who have agreed to accept certain rates, and steer patients toward those. If patients go to an out-of-network provider, they generally end up paying more.

Oklahomans who needed outpatient behavioral health care had an even greater disparity: they were eight times as likely to use out-of-network providers than people seeking similar medical care. The report didn't consider other types of restrictions, like how much patients must pay out-of-pocket for medications, and whether they are required to try cheaper drugs first.

So are the disparities a smoking gun that Oklahoma insurance plans are breaking the law? It's not so simple. For one thing, it's possible that other factors, like patients' reluctance to change therapists after beginning treatment, could explain part of the difference. There also could be legitimate explanations for paying some providers more than others.

The Oklahoma Insurance Department typically gets three or four complaints alleging parity violations each year, said Mike Rhoads, deputy commissioner of life and health insurance. In almost all cases, patients went out of network and were left with large bills — a difficult situation, but not a parity violation, he said.

The department also compiles market conduct reports, where staff examine a sample of an insurer's cases for parity violations and other problems, Rhoads said. The parity portion looks at whether insurers pay less for an initial behavioral health visit than for a primary care visit, and insurers typically pass muster, he said.

The comparison doesn't look at other services, because of the difficulty of finding matches. It also doesn't compare out-of-pocket costs or how many in-network providers a company has, though the department will look bring it up with companies if staff believe the network is inadequate, Rhoads said. Overall, he thinks Oklahoma insurers are following federal and state law.

“We've got some carriers in Oklahoma that get it,” he said.

Even state insurance regulators can't always tell if an insurance plan meets parity, however, according to a report compiled jointly by the National Center on Addiction and Substance Abuse, the Legal Action Center, the Partnership for Drug-Free Kids and the Treatment Research Institute. That makes it difficult for average patients to know if they have a case, let alone what they need to do to resolve the problem, the report said.

“Individuals do not have access to data necessary to show a violation that occurs at the systems level,” the report said.

Insurers point to efforts

Cigna, Aetna, Blue Cross Blue Shield of Oklahoma and United Healthcare all emphasized that they cover “medically necessary” services for substance use disorder.

Only GlobalHealth, in an email from Chief Operations Officer J. David Thompson, said it sets limits on inpatient and outpatient treatment days.

Blue Cross also said some of its grandfathered plans still could include limits of 30 days for inpatient care and 20 days for outpatient care, but that most of its plans don't include limits. Grandfathered plans were in place before the Affordable Care Act passed.

A few insurers say they've taken steps to make it easier to get treatment.

Rick Watson, senior medical director at Cigna for Oklahoma and north Texas, said the company reduced the paperwork needed to authorize treatment with methadone or buprenorphine. The two drugs are used to replace opioids without causing a high, so patients don't go through the withdrawal symptoms that could lead them to relapse.

Mark Friedlander, chief medical officer for Aetna Behavioral Health, said the company lists both medications as “preventative,” so customers don't need prior authorization and may have lower co-pays.

Representatives for United Healthcare said the company also doesn't require prior authorization for some addiction medications, including buprenorphine and naloxone, which can reverse an opioid overdose.

Blue Cross said it removed prior authorization requirements for medication-assisted treatment in February this year.

“We continue to provide our members with access to high-value, evidence-based health care treatments and encourage our members to speak with their doctors about the best treatment options available for their specific needs,” Blue Cross said in a statement.

Cigna also offers specialized case managers for people who appear to be at risk of a substance use disorder because they have multiple prescribers or take high doses, Watson said. The case manager can lay out options for treatment, if needed, he said. Customers aren't required to participate, though their employers may give them incentives to work with a case manager.

“We are not only reactive when someone is in need, but try to be proactive as well,” he said. “We want to get them back on the path to wellness.”

Aetna encourages patients to work with a case manager to come up with a treatment plan, Friedlander said. The hope is that reaching patients earlier will allow them to find options that meet their needs well, rather than whatever happens to be available in an emergency, he said.

“Many times people don't seek treatment until there's a crisis,” he said.

Questions about need

One reason for disparities may be that insurers are still confused, because the parity rules are relatively new, said Ky Humble, development director at The Recovery Center in Oklahoma City. The first parity law passed in 2008, and federal officials only began enforcing finalized regulations in January 2014. Before the Affordable Care Act expanded the 2008 parity law to cover more plans, most insurers wouldn't cover medications to assist with detoxification under any circumstances, he said.

Another problem is that it's difficult to tell whether legal restrictions, like requiring providers to show that services are medically necessary for a patient, are being used appropriately.

Insurance companies don't always agree with their assessment of a client's needs, such as whether a client needs medication to help with detox, Humble said. One company may agree to cover a medication, while another might think a client in a similar situation doesn't need it, he said.

“Different insurance companies require different levels of need,” he said.

Medical necessity criteria are based on the severity of patients' symptoms and their levels of functioning, which makes them somewhat subjective, Hanes said.

“A lot of times the criteria for medical necessity can be very high and somewhat obscure,” he said. “Each reviewer with an insurance company may have their own interpretation.”

The problem may go even deeper than differences in interpretation, however. Medical criteria sometimes aren't a good way to evaluate the needs of people with substance use disorders, said Pam Music, assistant to the business manager at Valley Hope Cushing. She said staff have to get on the phone with insurers nearly every day to try to extend a patient's stay beyond 14 days.

Patients may only have medical symptoms that need around-the-clock monitoring for the first few days of detox, Music said, but they may not be ready to stay away from the drugs while living in the community — and may not even have access to outpatient services if they live in rural areas, she said.

“After the first few days or week, people aren't going to have the tremors,” she said. “Anymore, (insurers) are looking at us to triage, get (patients) stable and send them out.”

Not paying for enough treatment for people who need to be in an inpatient program can set patients up to cycle in and out of treatment as they get out and relapse — which ultimately may cost insurers more in the long run, Music said. Or worse, patients may never return to treatment because they overdose after returning to drugs like opioids, she said.

“They're playing with people's lives, and that's something I can't tolerate,” Music said. “We're losing way too many people.”