Seeking help for a mental health or substance abuse problem can be an extremely challenging decision to make. Seeking help can be even more difficult when insurance providers deny coverage for treatment. Despite well-established generally standards of medical care – countless patients have found it frustrating – if not outright impossible – to secure mental health and addiction treatment coverage.
Drug and alcohol dependency are major risk factors that affect the health and wellbeing of millions of Americans. Sadly, 67,000 Americans died from opioid addiction in 2018 alone, while countless more struggled with addictions to other substances and mental health disorders. But despite the necessity and availability of treatment programs, many insurance providers deny coverage or fail to fully cover treatment that could mean the difference between life and death.
Why Do Insurers Deny Mental Health and Substance Abuse Coverage?
While insurers typically base coverage decisions on a case-by-case basis determined by their customer’s insurance plans, many who have been denied mental health and substance abuse coverage have reported similar rejections regardless of the insurer or policy.
Lack of “Medical Necessity”
One of the most common reasons insurers refuse to cover mental health and substance abuse treatment is because of a supposed lack of medical necessity. According to the insurers, because the policyholder’s addiction does not constitute an immediate need for lifesaving care, their treatment does not qualify for coverage. Disregarding the fact that mental health and substance abuse disorders are often chronic, the insurers may outright exclude, set arbitrary treatment limits, and refuse to pay for residential treatment for mental health and substance abuse disorder. In the case of substance abuse disorders, insurers may also refuse to cover or limit coverage for medication assisted treatment (“MAT”) and toxicology tests.
Limiting the Duration and Degree of Residential Treatment
The generally accepted standards of treatment for mental health and substance abused disorders are readily available to insurance carriers. But insurers may not always follow those standards. Instead, insurers are imposing more restrictive standards and telling patients they are covered only for outpatient care when they need residential treatment. Some insurers may not cover needed residential treatment at all.
Limiting the Duration and Degree of Care of Medication Assisted Treatment
Substance abuse treatment can be a long and extensive process. For many addictions, such as opioid dependency, the standard of care says a person will need lifelong care that includes carefully monitored alternatives like methadone. Because of the cost over time, many insurers will deny coverage outright or set improper limits on drug dosage limits, duration of treatment they will cover, or include caveats like refusing to cover additional treatments if the patient fails a drug test.
Limiting or Refusing to Cover Toxicology Testing Required for Medication Assisted Treatment
MAT Treatment providers are required to administer onsite toxicology screening for patients battling opioid addiction. The industry standard testing is 99% accurate, which is essential so physicians can properly administer care to their patients. However, many insurance providers will only pay for much cheaper testing that may only identify the type of drugs a patient is on 50% of the time. This substandard testing may not show the full extent of a patient’s need for substance abuse treatment, giving the insurer cover to deny coverage due to a lack of need.
What Can You Do if Coverage for Your Mental Health or Substance Abuse Treatment is Denied?
Unfortunately for people seeking treatment for substance abuse, they are often at the mercy – or lack thereof – of their insurance provider. Insurers have been making it increasingly more difficult for customers to seek treatment for chemical dependency and mental health issues. And while it is possible to file an appeal with your insurance provider, the process can be lengthy and cumbersome. Even then, there is no guarantee the insurer will agree to cover your treatment plan.
Wexler Wallace is currently investigating claims of insurance companies that disregard the applicable medical standards of care and set narrower coverage standards for mental health and substance abuse treatment. If your treatment was improperly denied by an insurance company, you may have grounds to take legal action. Contact our attorneys today and discuss your potential claim.