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http://www.democratandchronicle.com...cts-want-help-face-insurance-denials/5484139/
The client, a man in his 20s, was addicted to heroin and wanted help.
Medical professionals who evaluated him recommended an inpatient program — 10 days of around-the-clock care in a safe setting that offered medication, hot meals, counseling and coping skills to help him stay sober upon his release.
Then Richard Caruso, who oversees the treatment programs at Unity Health Systems' Chemical Dependency, called the man's insurance company for approval.
Sunday feature: Heroin reaching into the suburbs
Caruso recalled that the man had coverage,o but the insurer declined to pay unless he had first failed to stay clean in a less expensive outpatient program, a nine-month regimen of voluntary therapy and medication.
"That's a typical response from an insurance company," Caruso said. "There are a lot of people who need inpatient services but because of denials from insurance companies are in outpatient."
As the region grapples with a sharp rise in heroin use, addicts and their loved ones who are searching for help are contending with a shortage of services and constraints placed on care by insurance companies, health care and addiction specialists say.
Demand for treatment is quickly outstripping supply, leaving addicts whose internal clocks revolve around their next fix to wait weeks in some cases for care ranging from scheduling counseling sessions to getting medicine to combat withdrawal.
The obstacles are perhaps felt more acutely by the heroin addicts of today, whom specialists characterize as younger, more affluent and more naïve than users of the past, who were generally of lesser means and more hard-bitten to bureaucracy.
For example, specialists say before insurance companies agree to cover inpatient services they want evidence that an addict has tried one or more outpatient programs, has little or no outside support network, and has a health condition that makes treatment a medical necessity.
"A lot of these heroin users now have families, and the insurers aren't looking at them the same way as someone who's homeless or living in a drug house," said Robert Lebman, president of Huther Doyle, an addiction treatment center in Rochester.
James Redmond, a spokesman for Excellus BlueCross BlueShield, a major insurer in the Rochester area, said the company examines a host of clinical evidence to determine whether inpatient services are necessary.
"These are very fact-sensitive determinations and, in some circumstances, the applicable evidence-based clinical criteria require outpatient treatment attempts before coverage is approved for inpatient services," Redmond said.
The story continues: http://www.democratandchronicle.com...cts-want-help-face-insurance-denials/5484139/
The client, a man in his 20s, was addicted to heroin and wanted help.
Medical professionals who evaluated him recommended an inpatient program — 10 days of around-the-clock care in a safe setting that offered medication, hot meals, counseling and coping skills to help him stay sober upon his release.
Then Richard Caruso, who oversees the treatment programs at Unity Health Systems' Chemical Dependency, called the man's insurance company for approval.
Sunday feature: Heroin reaching into the suburbs
Caruso recalled that the man had coverage,o but the insurer declined to pay unless he had first failed to stay clean in a less expensive outpatient program, a nine-month regimen of voluntary therapy and medication.
"That's a typical response from an insurance company," Caruso said. "There are a lot of people who need inpatient services but because of denials from insurance companies are in outpatient."
As the region grapples with a sharp rise in heroin use, addicts and their loved ones who are searching for help are contending with a shortage of services and constraints placed on care by insurance companies, health care and addiction specialists say.
Demand for treatment is quickly outstripping supply, leaving addicts whose internal clocks revolve around their next fix to wait weeks in some cases for care ranging from scheduling counseling sessions to getting medicine to combat withdrawal.
The obstacles are perhaps felt more acutely by the heroin addicts of today, whom specialists characterize as younger, more affluent and more naïve than users of the past, who were generally of lesser means and more hard-bitten to bureaucracy.
For example, specialists say before insurance companies agree to cover inpatient services they want evidence that an addict has tried one or more outpatient programs, has little or no outside support network, and has a health condition that makes treatment a medical necessity.
"A lot of these heroin users now have families, and the insurers aren't looking at them the same way as someone who's homeless or living in a drug house," said Robert Lebman, president of Huther Doyle, an addiction treatment center in Rochester.
James Redmond, a spokesman for Excellus BlueCross BlueShield, a major insurer in the Rochester area, said the company examines a host of clinical evidence to determine whether inpatient services are necessary.
"These are very fact-sensitive determinations and, in some circumstances, the applicable evidence-based clinical criteria require outpatient treatment attempts before coverage is approved for inpatient services," Redmond said.
The story continues: http://www.democratandchronicle.com...cts-want-help-face-insurance-denials/5484139/