An Uphill Battle for the Honest


insurance agent

The system has been flawed as long for as I can remember.

Ten years ago, managed care organizationsmanaged care organizations were the primary and foremost referral agents for those seeking addiction treatment. Most patients or family members of patients would access the channel of his or her own medical insurance plan. This was bad of course, because managed care organizations would often do everything in their power to limit length of stay or deny coverage altogether. Managed care was always a nightmare to deal with in fighting for coverage for patients in need. Utilization review specialists often had to be "creative" in making a case for access to insurance benefits.

The result: patients and their families would be left with the burden of making up the difference for what managed care would not provide - or stay for a small portion of their recommended treatment plan. It didn't work.

Since that time, and the growing popularity of Internet search enginesInternet search engines, insured members find substance abuse treatment providers independently and often through misleading call-centers/ patient brokers, who make promises over the Internet. Head hunters get paid top dollar by out-of-network providers for PPO insured or well-funded candidates.

Now as some unscrupulous entrepreneurs build profitable businesses through unethical practices, their abundant marketing budgets have overtaken the market. Ethical, in-network, insurance contracted providers do not have comparable marketing capital to compete. They operate off of a highly discounted rate of reimbursement, which result in meager marketing / promotion budgets. It's a disadvantage from the very beginning and high-quality care is being passed over for providers looking to make as much profit as possible.

As a result, ethical providers have incentive to drop or avoid insurance contracts. Reimbursement is too low and contractual restrictions are too high.

The entrepreneurs are being rewarded by the same PPO plansPPO plans they abuse, by being paid a percentage of their indiscriminately escalated "usual and customary" rates. Essentially a "kick-back." Rather than managing continuing care where the patient resides, the PPO carrier enable the continuation of long residential stays away from home. Insurance carriers willingly pay out-of-area residential programs to extend residential stays by using the day treatment and intensive outpatient treatment benefit, while the patient continues to reside in residential, away from home care. No benefits are left to assist the patient integrate recovery back where the wreckage, triggers and real-life problems reside.

Not so long ago, treatment providers had to wrestle with managed care carriers for as much care as possible, which usually wasn't enough. Now, patients are misguided by misleading call centers so that marketing entrepreneurs and out of network providers can financially benefit. Both scenarios leave ethically-minded providers lagging behind and also hurt the patients who are unknowingly part of a marketing machine - and not being steered to the highest quality of care - including an aftercare plan upon returning home.

It will require a collective effort to raise awareness for these unethical practices and hopefully someday impose reform to level the playing field. Before that happens, getting patients into high quality care facilities remains an uphill battle for the honest.

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