Covering Treatment for Addiction | Video

Retha Colclasure | 2/25/2013

When a sick patient shows up at the Heartview Foundation to seek care for a drug or alcohol addiction Heartview will first figure out what kind of treatment is most appropriate. Then, the patient`s insurance provider is asked to cover it. In the past, that`s all it had to do to begin providing that treatment.
But now, the game seems to have changed.

Kristin Sande has been alcohol-free for one year. And she says there`s no way she could have done it without a 28 day stay at the Heartview Foundation.

"The most important thing about the treatment for me was that I was there. I could be somewhere safe, there wasn`t any alcohol and I couldn`t leave and go get any."

Inpatient treatment is an essential tool for places like Heartview as it provides a safe, supportive setting for someone to get away from sometimes bad living situations. Executive Director Kurt Snyder says they`re seeing insurance companies becoming very focused on just the medical needs of patients, like withdrawal or mental health issues.

"Access has definitely become more difficult, if they don`t have those medical issues, if their issues are more about their living situation, we find access to residential is difficult to get paid for by insurance companies."

Snyder says there have been about a dozen cases in the past two years where Heartview wanted to provide more intensive services than what the insurance companies would approve. So Heartview filed a complaint with the North Dakota Insurance Department last year. It`s one of four complaints about addiction coverage the department received in 2012.

"We took a complaint to them, how do we effectively treat people when the ball is moving. That`s a fair complaint on our part, still is a fair complaint because according to criteria, there`s clear guideline and providers continue to disagree with BCBS about what those actually mean for people," Snyder said.

A representative for Blue Cross of North Dakota provided a written response to emailed questions and says, "Yes, there has been a change in the percentage of coverage requests approved" since adopting a set of guidelines commonly used to determine the appropriate level of care for patients.

Blue Cross says they want to be good stewards of health care dollars and see a challenge of providing the coverage for addiction treatment without impacting policy premiums. They point out that if the Affordable Care Act really works, "there will be millions more clients eligible for definitive addiction treatment who now are not covered by insurance or public funding."

Snyder says there are some things to be gained from this conflict.

"Our criteria, we needed to look at that. We need to be better about applying that criteria. Not everybody needs residential."

But he says residential treatment, which can range from $120 to $750 a day, is an important part of helping addicts, like Sande, recover.

"It saved my life. It was a safe spot to be for 28 days, gave you that time to remember what life was like without it. I was never able to get that myself," Sande said.

Snyder says the discussions with Blue Cross continue, and says providers do need to make sure what they`re offering to patients is medically necessary. He says he believes there is middle ground, and hopes to be able to reach it.

Snyder also says, so far, Heartview has continued to provide the services it believes is necessary for patients, even when insurance hasn`t covered it. He says they`ve just had to eat the cost. But, he points out, that is not a long-term, sustainable solution, especially as the center is continuing to see more and more demand for services.

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