A Pennsylvania Commonwealth Court has ruled that HMOs and group insurance companies must cover drug and alcohol treatment costs for policy holders referred to detoxification, rehabilitation and outpatient programs by a doctor or psychologist. The unanimous decision will help about 15,000 state residents with private insurance who need help through drug detox and drug rehab each year.
A 1989 state law requires insurance companies to cover drug and alcohol detox and rehab services. Aetna, Independence Blue Cross, the Insurance Federation of Pennsylvania and other managed-care groups sued the state’s Insurance Department, saying that they should be allowed to review drug and alcohol treatment referrals to make sure that treatment is appropriate. But the court sided with the Insurance Department’s interpretation that treatment would be covered as long as a doctor or psychologist prescribed the alcohol or drug rehab program.
“It’s a really important decision,” said Deborah Beck, president of the Drug and Alcohol Service Providers Organization of Pennsylvania. “Somebody at the end of an 800 number in another state should never be making these decisions.”
The insurance industry could appeal to the state Supreme Court and argue that state law allows insurers to review treatment in other health care areas before paying for care, and that it’s reasonable that alcohol and drug detox and drug rehab programs should be treated the same way. The insurance industry’s reviews of alcohol and drug rehab referrals would be conducted by physicians and psychologists, an Insurance Federation of Pennsylvania spokesman said, adding that when you don’t have scrutiny over treatment patterns, you get increased health care costs.
However, doctors and psychologists who review cases for the insurance companies are paid by the insurance companies. Although this fact was not openly considered as part of the court’s ruling, the fact remains that reviewers’ decisions could tend to favor their employers – the HMOs and insurance companies – rather than the addicts, whos own treatment professionals have already determined that they need alcohol and drug detox and drug rehab programs.
Battling with HMOs and group insurers over desperately needed coverage is nothing new to Americans. The issue has been widely popularized in several books and movies that detailed the horrors resulting from the insurance industry’s penchant to favor their bottom line ahead of patient health.
According to Beck, slowing down the availability of alcohol and drug rehab through a complicated approvals process places addicts at risk. They might “disappear and die,” she said, adding that the court ruling upholds a “life-saving” law.
After nearly two decades on the books, the Pennsylvania law may finally have the chance to accomplish its intentions – to get people suffering from substance abuse and addictions into an alcohol or drug rehab program as quickly as possible.