Newcomer...frustrated by insurance
Member
Thread Starter
Join Date: Sep 2008
Location: Syracuse,NY
Posts: 4
Newcomer...frustrated by insurance
Hello all! I'm new to the forum, registered a few days ago and have been reading up.
I gave my AH the choice of my divorce lawyers name or getting help almost 2 weeks ago. He made all his own arrangements and we checked him into inpatient care on Monday. It's been a tough week but I've been very focused on my own recovery.
Today I got a call from his case manager. His insurance is denying his inpatient care. They covered detox but said he should attend outpatient instead. I am so frustrated by this. He attended an Outpatient at the same place in 2001 and relapsed in about 8 months. Last summer he got a DWI. His court mandated evaluator recommended intenstive inpatient treatment. Somehow he got that reduced and only had to do another Outpatient from January of this year until June. He drank the entire time and they knew it, but graduated from the program anyway. Now they want him to come home again and go outpatient when our insurance coverage clearly states that he is 100% covered for up to 60 days of inpatient treatment per year.
Has anyone else experienced this?
I gave my AH the choice of my divorce lawyers name or getting help almost 2 weeks ago. He made all his own arrangements and we checked him into inpatient care on Monday. It's been a tough week but I've been very focused on my own recovery.
Today I got a call from his case manager. His insurance is denying his inpatient care. They covered detox but said he should attend outpatient instead. I am so frustrated by this. He attended an Outpatient at the same place in 2001 and relapsed in about 8 months. Last summer he got a DWI. His court mandated evaluator recommended intenstive inpatient treatment. Somehow he got that reduced and only had to do another Outpatient from January of this year until June. He drank the entire time and they knew it, but graduated from the program anyway. Now they want him to come home again and go outpatient when our insurance coverage clearly states that he is 100% covered for up to 60 days of inpatient treatment per year.
Has anyone else experienced this?
Member
Join Date: Jan 2007
Location: Milwaukee WI
Posts: 137
this is the same thing that happened to us....he should have had inpatient too, only detox and then into outpatient...I tried to voice my thoughts to the therapist, but was told that it was up to the insurance company....
Ph.D in insanity!!
Join Date: Sep 2008
Location: Florida
Posts: 698
Talk to who ever does the billing at the front desk. It may just be who is ever doing the coding. Talk to the office supervisor and make sure this is not the case. Sometimes if you talk nicely they will change the code so that your insurance approves it 
I had to go through this with my ah.
I had to go through this with my ah.
Restoring myself to sanity
Join Date: Sep 2007
Location: Georgia
Posts: 1,018
Yep, I have experianced this and it is so frustrating.
My MIL and I were planning on doing an intervention. We had a great rehab facility all picked out and everything. Turns out my insurance will only cover detox not inpatiant stay. Basicly my AH can go out get high, check in a hospital and detox for three days and the insurance will pay for this. He can repeat this cycle for 30 calander days in a year. Yet my stupid insurance will not pay for him to get 30 consecutive days of treatment. Our lovely, lovely healthcare system at work!!!!!!
The rehab we selected costs 30K, and they require a 13K deposit then they will work with you on the rest with intrest free payments. My MIL said she will pay for it but she wants to wait a while. How can I blame her for that. 30K is a lot of money for someone to pay and not have the treatment work. He has to be ready and right now, my AH is not wanting to be clean....
My MIL and I were planning on doing an intervention. We had a great rehab facility all picked out and everything. Turns out my insurance will only cover detox not inpatiant stay. Basicly my AH can go out get high, check in a hospital and detox for three days and the insurance will pay for this. He can repeat this cycle for 30 calander days in a year. Yet my stupid insurance will not pay for him to get 30 consecutive days of treatment. Our lovely, lovely healthcare system at work!!!!!!
The rehab we selected costs 30K, and they require a 13K deposit then they will work with you on the rest with intrest free payments. My MIL said she will pay for it but she wants to wait a while. How can I blame her for that. 30K is a lot of money for someone to pay and not have the treatment work. He has to be ready and right now, my AH is not wanting to be clean....
Member
Thread Starter
Join Date: Sep 2008
Location: Syracuse,NY
Posts: 4
My FIL has gone ahead and paid until Tuesday but we are still fighting the insurance company. In the case that we lose our appeals, he has agreed to pay for it. We spoke about it and decided it's best not to tell my AH about this right now. He needs to focus on himself and his recovery.
I did some research online and found out that this is happening to a lot of people. The state of PA actually made it a requirement that Insurance Companies pay for it. It boggles my mind that any other disease would be covered but this doesn't seem to be taken as seriously.
I have a lot of work to do on my own recovery right now, but this will remain in the back of my mind. I feel very strongly that something must be changed here. When I am in a better place, I will make working for reform on this a priority. Families dealing with addiction have enough to worry about, fighting to get help for our loved ones shouldn't be one of them.
I did some research online and found out that this is happening to a lot of people. The state of PA actually made it a requirement that Insurance Companies pay for it. It boggles my mind that any other disease would be covered but this doesn't seem to be taken as seriously.
I have a lot of work to do on my own recovery right now, but this will remain in the back of my mind. I feel very strongly that something must be changed here. When I am in a better place, I will make working for reform on this a priority. Families dealing with addiction have enough to worry about, fighting to get help for our loved ones shouldn't be one of them.
Restoring myself to sanity
Join Date: Sep 2007
Location: Georgia
Posts: 1,018
The person I spoke to at the rehab facility told me this happens more often then naught..
It's so so sad that health care will pay for viagra but not treat a disease like addiction.
It's so so sad that health care will pay for viagra but not treat a disease like addiction.
Ph.D in insanity!!
Join Date: Sep 2008
Location: Florida
Posts: 698
Originally Posted by jerect 
The person I spoke to at the rehab facility told me this happens more often then naught..
It's so so sad that health care will pay for viagra but not treat a disease like addiction.
It's so so sad that health care will pay for viagra but not treat a disease like addiction.
Member
Join Date: Nov 2004
Location: WA Rainforest
Posts: 209
We had an HMO and they did the same thing. they would pay for detox, and for outpatient, and for inpatient only for 14 days, even when the ER doctor said he needed to be in a 28 day program and got him into one, the HMO made them discharge him after 14 days.
Basically they only did just barely enough that I wouldn't have been able to sue them for negligence in case he killed himself.
On the other hand there's no knowing that he would have been 'healed' even after 28 days. Unlike other diseases, recovery is to a great extent a matter of his will. And he didn't want to get better. One of the in-house counselors told me that the HMO's research showed that it didn't matter how long As spent in in-patient recovery, that the outcomes were statistically the same for any length of treatment, so the HMO was limiting stays to 14 days. It is incredibly expensive treatment after all. But to me this suggests that doing nothing at all is just as effective as the full 28 day program, so the HMO's treatment program must be pretty ineffective. And it sure was for him.
They did fully cover his 7 days in the psych ward though, after one suicide attempt. So if he can be diagnosed as mentally ill ... although the Behavioral Health dept. at this HMO was just as bad, did the absolute minimum to keep him from killing himself outright.
It's not about healing, it's about cost containment. But, realistically, it's an incredibly expensive and difficult disease to treat, with no guarantees of any success. Too much depends on the will of the patient rather than the treatment provided. His parents looked briefly into private rehab, they're easily wealthy enough to have afforded it for him, but even the ones with the best reputations only claimed about a 50% 'success' rate, meaning still not drinking 1 year from discharge, and we all know that that's not exactly a cure! I wouldn't want to spend that kind of money (in the $30k range) for such pathetic results.
Basically they only did just barely enough that I wouldn't have been able to sue them for negligence in case he killed himself.
On the other hand there's no knowing that he would have been 'healed' even after 28 days. Unlike other diseases, recovery is to a great extent a matter of his will. And he didn't want to get better. One of the in-house counselors told me that the HMO's research showed that it didn't matter how long As spent in in-patient recovery, that the outcomes were statistically the same for any length of treatment, so the HMO was limiting stays to 14 days. It is incredibly expensive treatment after all. But to me this suggests that doing nothing at all is just as effective as the full 28 day program, so the HMO's treatment program must be pretty ineffective. And it sure was for him.
They did fully cover his 7 days in the psych ward though, after one suicide attempt. So if he can be diagnosed as mentally ill ... although the Behavioral Health dept. at this HMO was just as bad, did the absolute minimum to keep him from killing himself outright.
It's not about healing, it's about cost containment. But, realistically, it's an incredibly expensive and difficult disease to treat, with no guarantees of any success. Too much depends on the will of the patient rather than the treatment provided. His parents looked briefly into private rehab, they're easily wealthy enough to have afforded it for him, but even the ones with the best reputations only claimed about a 50% 'success' rate, meaning still not drinking 1 year from discharge, and we all know that that's not exactly a cure! I wouldn't want to spend that kind of money (in the $30k range) for such pathetic results.
Yield beautiful changes
Join Date: Feb 2008
Location: A home filled with love
Posts: 1,698
We had the same ridiculous insurance issues when AH decided to find a treatment facility.
We got authorization for the stay, spoke to the facility in advance, did everything "by-the-book", and the insurance company still denied the claim.
Unfortunately, they made that decision after AH had been there for 10 days and racked up several thousand dollars in charges.
At the time, I was lived. I had a lot of hope pinned on inpatient rehab - it was our last chance.
Now I can understand why the insurance company would be hesitant to pay. The money that we ended up spending to keep him there for 28 days has not been sufficient to keep him sober. I guess they had the statistics to prove what I so desperately wanted to avoid being true - my AH was likely to drink again, with or without rehab.
I'm sorry that you're going through this hassle. It's a very frustrating experience.
You're in my thoughts.
-TC
We got authorization for the stay, spoke to the facility in advance, did everything "by-the-book", and the insurance company still denied the claim.
Unfortunately, they made that decision after AH had been there for 10 days and racked up several thousand dollars in charges.
At the time, I was lived. I had a lot of hope pinned on inpatient rehab - it was our last chance.
Now I can understand why the insurance company would be hesitant to pay. The money that we ended up spending to keep him there for 28 days has not been sufficient to keep him sober. I guess they had the statistics to prove what I so desperately wanted to avoid being true - my AH was likely to drink again, with or without rehab.
I'm sorry that you're going through this hassle. It's a very frustrating experience.
You're in my thoughts.
-TC
Member
Thread Starter
Join Date: Sep 2008
Location: Syracuse,NY
Posts: 4
I know there are no guarantees that he will be sober after the 28 days, but I look at it this way: There are no guarantees that cancer will be cured after a series of chemo treatments either, but that shouldn't give the insurance company the right to decide not to cover it for that reason.
I'm still fighting and the FIL keeps paying. No matter what, we're going to give him the chance he deserves. I'll keep you all posted!
I'm still fighting and the FIL keeps paying. No matter what, we're going to give him the chance he deserves. I'll keep you all posted!
Retired Pro Drunk
Join Date: Jul 2006
Location: Saint Paul, MN
Posts: 901
Few things...
Make sure you have a copy of your summary plan description (the book). A benefit summary guide or insurance "at a glance" isn't the same. If you don't have one, check with the employer who sponsors the plan or with the ins co. (depending on if the plan is self-funded or not) to obtain a complete summary plan description.
Familiarize yourself with the sections regarding preadmission notification, prior authorization, claims and appeals procedures, and general exclusions (in addition to benefits for substance abuse/alcoholism).
Contact your case manager at the facility and verify that the documentation they sent the ins co. was signed by an M.D. (as opposed to a counselor). The facility should have a few physicians on staff.
What the ins. co. is telling you at the moment is that they don't feel inpatient treatment is medically necessary. This could be due to the documentation that was sent by the facility. You may also need to find out the criteria for which inpatient treatment is warranted. If you can get this (from the ins. co.) in writing, do it and get it to the facility.
If the facility can justify medical need based on your ins. cos. criteria, and the documentation is signed by an M.D., you should be good to go.
Make sure you have a copy of your summary plan description (the book). A benefit summary guide or insurance "at a glance" isn't the same. If you don't have one, check with the employer who sponsors the plan or with the ins co. (depending on if the plan is self-funded or not) to obtain a complete summary plan description.
Familiarize yourself with the sections regarding preadmission notification, prior authorization, claims and appeals procedures, and general exclusions (in addition to benefits for substance abuse/alcoholism).
Contact your case manager at the facility and verify that the documentation they sent the ins co. was signed by an M.D. (as opposed to a counselor). The facility should have a few physicians on staff.
What the ins. co. is telling you at the moment is that they don't feel inpatient treatment is medically necessary. This could be due to the documentation that was sent by the facility. You may also need to find out the criteria for which inpatient treatment is warranted. If you can get this (from the ins. co.) in writing, do it and get it to the facility.
If the facility can justify medical need based on your ins. cos. criteria, and the documentation is signed by an M.D., you should be good to go.
Member
Join Date: Jun 2007
Location: Arlington, VA
Posts: 4,290
It is my experience that it is very difficult to get insurance companies to pay for any sort of in patient mental health care. My son is bipolar and the few times it was necessary to have him hospitalized it was a major battle to get him admitted and for hte length of time his pyschiatrists recommended. I am sure its even more difficult for an addiction.
I wish you luck. My only suggestion is trying to get the docs to change the codes they use to submit the claims. That sometimes can help.
I wish you luck. My only suggestion is trying to get the docs to change the codes they use to submit the claims. That sometimes can help.
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