Does Blue Cross Fuel Addiction by Sending Payment to Addicts Instead of Treatment Providers?

Posted by Joan Borsten on February 10, 2012

You are an alcoholic or drug addict in the earliest stages of recovery.  You just finished rehab.  On admission you assigned your insurance benefits to the treatment center.cashing check triumphantly.jpg

Suddenly you get a very big check in the mail from your Blue Cross Health Plan, made out to you.  Obviously the money is intended is for the treatment center.   Do you forward it to the treatment center?  Or do you cash the check and spend the money? 

According to alcohol and drug treatment centers up and down the State of California more often than not, the check leads right back to an expensive drug addiction, or triggers a “secondary” addiction like gambling, shopping or overspending.

Is it possible that Anthem Blue Cross of California, Blue Cross of Hawaii and Blue Cross of Washington State – to name a few --  are unaware that the American Society of Addiction Medicine (ASAM) recently updated their definition of addiction to “chronic brain disease?”

Sending the check intended to pay for treatment to the addict or schizophrenic is not like sending a check to someone who broke a leg.

As a supervisor at Blue Shield put it, whenever a claim comes in with a mental health code the system should automatically direct payment to the provider.

Last year we learned the hard way about payment policy of some of the Blue Crosses.  Our client was Colin (not his real name), 32.  In addition to being addicted to prescription pills, he and his Significant Other were very entitled "big spenders" – designer clothes, first class travel, fine dining.  While in treatment, instead of washing his clothes, Colin sent everything out to be cleaned.

Colin's insurance policy only covered part of the treatment costs, and of course he was broke, so his elderly grandparents borrowed money against their social security and pension payments, and his parents cashed out part of their nest egg. 

When we discovered --  to our horror -- that the local Blue Cross, in accordance with their policies, had issued payment to Colin, we were terrified.   We learned through the family Colin and his Significant Other were on vacation in Mexico.  When the couple got home they quickly deposited the check and told the parents no check had arrived.  When Blue Cross confirmed the check had been cashed, Colin told his parents it was a different check.  The parents were ordered to stop communicating with us.  The Significant Other threatened a law suit and hired a lawyer. Obviously Colin was entitled to a financial reward for having completed 30 days of treatment. Fortunately for us, the lawyer insisted that the proceeds of the check be deposited into his client trust account, and then wired us the money.  

Other rehabs have not been so lucky.  One lost $130,000 when clients made off with payments. 

The patient of another treatment center returned home and to his surprise found several large checks waiting for him. By that time he had lost his job and was collecting unemployment.  He hd bills to pay.  So he made a unilateral decision as to what he thought his treatment was actually worth, and kept the rest for himself.    

There ought to be a law.

Julia F: 90 Days of Rehab Courtesy of Starbucks

Posted by Joan Borsten on December 03, 2011

When we first opened the doors at Malibu Beach Recovery Center, our clients paid cash.  The reasons werestarbucks coffee.jpg obvious – in those days, no one wanted their employer or insurance to know they had an alcohol or drug problem. The employer might fire you.  Using your insurance would create a “pre existing” condition that might prevent you from getting new insurance if you changed jobs.   In those days even if you did not have money in the bank you could get a second on your house, or use the line on your credit card to pay for treatment. 

Then the economy tanked and slowly the cash clients began to fade into the sunset.  There are still some but now most clients are those with what we call “Cadillac” insurance.  The best of these policies are provided by big companies and big states  (like New Jersey) to their employees.

The policies are sometimes so rich in benefits that those seeking recovery from addiction are authorized for 60-90 days at a time, sometimes in differing levels of care, but the combined total of days dramatically raises the odds of long term recovery.   According to studies by the National Institute of Drug Addiction (NIDA):“Individuals who complete at least 90 days of treatment in a Therapeutic Community have significantly better outcomes on average than those who stay for shorter periods.”

Julia (not her real name) came to Malibu Beach Recovery Center through the excellent health insurance Starbucks provides employees.  

Her early years were not unlike those of Robert Downey, Jr.   Her parents were in the music industry.  Mom smoked marijuana and took pills -- “she was well connected with doctors and shrinks.”  Dad smoked marijuana and free based cocaine.  Julia was introduced to marijuana when she was 12; Seconal, Quaaludes, and speed in pill format at 14.  “I had to reach a certain age to try a certain drug,” she said.   After her mother started dealing cocaine, she and Julia began using together.  Julia was then 15.  Julia  "didn’t like cocaine but I did like getting high.”  At 18 she moved to California to live with her father “who had cocaine and crystal meth all over the house.”  Her first husband turned her onto heroin.  

Julia’s first rehab was at age 24.  Six more followed.  All for 30 days or less.  Nothing could keep her away from drugs.  

It took another 25 years to "hit bottom."  One evening earlier this year she overdosed in front of China, her young daughter.  Not surprisingly, Child Protective Services took China away.  That was when Julia "decided it was over" and entered treatment at Malibu Beach Recovery Center.

I am not telling Julia’s story because it is so horrific and seemingly hopeless, or because she is "cured."  No such thing.  Addiction is a chronic brain disease.  But I wanted to document the fact that there are some pretty great health insurance companies out there such as Premera, third party admnistrator of the Starbucks' enlightened employee health plan.  Premera was able to authorize 90 days of treatment for a woman who needed at least that (and got more by following residential treatment with sober living).  If the clinical tests of NIDA, and our hand's on experience here at Malibu Beach Recovery Center, are correct, Starbucks may never have to invest in residential treatment for Julia again.  Except maybe a 5-7 day "tune up."

Only time will tell but next week Julia celebrates 7 months of sobriety.  She now has a good job, and has impressed Child Protective Services with her commitment to long term sobriety.

Here’s the letter we  received last month from Julia:

Joan:   I arrived at LAX exactly 6 months ago today!  It was after midnight when I finally got to Malibu.  Sergei picked me up.  I had received a text saying “I will be in baggage claim with a sign.  PS I’m bald.”  I found him.  I had just bought myself a latte at Starbux as I knew it might be the last for a long time.  I remember smiling standing in front of him, seeing the sign and being extremely excited to be in Los Angeles, California.  We pulled into MBRC and I felt so relieved that it was over.  I had no idea what was to come.  MBRC allowed me to go through all of my anxiety, bad memories, feelings, pain, experiences.   Then more time to come out of the other side of it.  I don’t know how to ever thank you  except to stay clean.  The 3 months in Malibu, the 2 months at Brentwood House was just what I needed.  You gave me the time to heal.  I am back in New York and ready to take on the world, especially got my daughter back.  We’ve been spending lots of time together.  Thank you for my life.

PS  I got a terrific job selling cars with pay and commission.  So excited.  I love sales and there is so much $ to be made.  I’m so grateful to Joe (the Manager of Brentwood House Sober Living) who always said:  “Stop watching TV or your life will pass by and you’ll get high.”  As I was watching TV I thought, wow is he right.  I was hired on the spot.  Already went through training.

Anthem Blue Cross of California: As cheap as it comes

Posted by Joan Borsten on April 13, 2011

On July 20, 2010 I reported on the nightmare we went through trying to get Anthem Blue Cross to pay for treatment of a client whose stay was fully authorized.  Although we were ultimately successful, many executive hours were spent forcing Anthem to approve payment, cut and mail the check. anthem_blue_cross.LEDE[1].jpg

I was not as lucky getting reimbursement for another client who was treated in 2007-2008.  The claim had been rejected repeatedly because we were not Medicare Providers.  Of course not. Client is not on Medicare and alcohol and drug treatment is not even covered by Medicare.   

Finally I called the office of State Senator Fran Pavley who represents Malibu in the California legislature.  Her staff put me in touch with an Anthem lobbyist.  She directed me to someone who waived the Medicare requirement.  At that point, our alum who had paid for treatment in 2007-2008 was finally reimbursed for the benefit he had faithfully paid for month after month, year after year. Thank you Senator Pavley and your dedicated team.

So what about the 2010 clients who still needed their reimbursement?

By contrast with Blue Cross/Blue Shield of New York, Texas, New Jersey, Tennessee, Michigan. Washington, and several other states we know about, all of which have fair, even generous benefits for chemical dependency treatment, the standard Anthem Blue Cross of California coverage is worth less than $6,000.  And you have to fight to get it. 

Here are some examples:

Client John, a diagnosed schizophrenic, was on probation for having shot up his parent’s upper middle class neighborhood with a rifle while drunk.  When he opened the front door and started tossing beer cans into the street, the terrified neighbors called the police. 

Anthem refused to pay for his treatment.  Why?

1)      John can be “safely treated” in the community. 

2)      John does not have a severe medical disorder for which he needs constant supervision while receiving treatment. 

This brilliant determination was made by two Anthem Medical Reviewers who our lawyer insists we cannot name. They definitely deserve to have a schizophrenic like John move in next door and drive past their children every day to attend a community outpatient program.

Client George is legally blind. He came in addicted to opiates and benzodiazapines.    It took about 5 days to detox him from opiates, 30 days to get him off benzos.   For most of treatment a counselor had to be at his side, to makes sure he did not fall down or walk into a wall.   What did the wise Anthem doctors determine?

1)      George can be “safely treated” in the community. 

2)      George does not have a severe medical disorder for which he needs constant supervision while receiving treatment. 

Dear Anthem Doctors:  George actually saved Anthem money by going to residential treatment.  It would have cost Anthem much more to pay someone to drive George to and from outpatient treatment, and then remain at his side around the clock to make sure he did not slip and fall at home from the effects of getting off drugs.  Even a Certified Nursing Assistant costs $20/hour.  

Then we had a client we will call Sam.  Addicted to speed balls (a combination of heroin and cocaine), on arrival he tested positive for opiates, methamphetamine, amphetamine and benzodiazapines.  He reported having had hallucinations and hearing voices.  He had an abcess in his right forearm which was filled with gauze.  He could barely stand and complained of nausea.   His terrified parents paid for treatment.  We agreed to help them get reimbursement for the small amount of money their Anthem policy provided for chemical dependency treatment.

We called Anthem to get authorization for detox.  Impossible though it seems, this part of his chemical dependency benefit was denied.  We moved to Plan B: Residential Treatment (living at the center 24/7 and going to individual therapy, group therapy, family therapy, doing 12 Stepwork).   Also denied.   In the end, Anthem authorized 5 days of “Partial Hospitalization” (for which they pay even less than the pittance they allow for detox and residential treatment).  

This means that the Anthem clinical team determined that Sam, though almost comotose and craving drugs, was perfectly able to live at home and commute to treatment each day. When I called back after 5 days, additional days of "Partial Hospitalization" were denied because Sam was still detoxing.

I heard an even worse story from the director of a treatment facility in Northern California. An Anthem client completed residential treatment and was stepped down to an outpatient program.  Anthem refused to pay because they now knew the client had a "pre-existing condition."

 

 

Malibu Beach Recovery Center to offer SAG Tier II Health Plan members creative financing options

Posted by Joan Borsten on December 25, 2010

The approximately 12,000 Screen Actors Guild members who have health benefits under the Screen Actors Guild Tier II Health Plan will begin paying privately for chemical dependency benefits beginning January 1, 2011  -- or doing without.  This represents a serious setback for an industry where alcohol and drug abuse is rampant. SAG-Logo-2009_large.jpg

As we (Malibu Beach Recovery Center) have accepted Plan I and Plan II SAG insurance since 2008, we now plan to offer SAG Plan II members some creative alternatives to help them pay for treatment in 2011.

My husband Oleg Vidov is a member of the Screen Actors Guild which has a boutique, self-insured health care plan jointly operated by representatives of SAG and the entertainment industry.    We have had SAG health insurance for more than 20 years, and have always been grateful to our Health Plan for its generous benefits and great customer service.  

The difference between being Plan I and Plan II is how much you earned the previous 12 months from a combination of new movie roles, new appearances on TV and new commercials as well as residuals from repeat showings of older work. Many well-known actors whose careers have floundered have come to us as Plan II, only to become Plan I again after landing a good role.

Plan II tier actors have always had more limited benefits for chemical dependency than Plan I.  But now they have none because of federal requirements that the SAG Health Plan comply with “The Mental Health Parity and Addiction Equity Act” which was signed into law in 2008.   The tragedy is that the bill’s supporters expected it to increase, not decrease, mental health and substance abuse benefits for the country's insured.

On December 23, 2010 Russell Adams and Avery Johnson, writing for The Wall Street Journal, said the Guild's health plan represents one of a small number of unions, employers and insurers that are scrapping such benefits for their enrollees because the 2008 Act requires mental-health and substance-abuse benefits, if offered, be as robust as medical or surgical benefits. By dropping such coverage, providers can circumvent the requirements.

The SAG Health Plan --which currently covers 40,000 actors, stuntmen, TV actors and musical performers -- is facing a $30 million deficit this year with projections of a $50 million deficit next year.

Dave McNary, who has been covering changes to the SAG Health Plan for Variety, the film industry’s daily trade paper, wrote: “The tightened requirements aren't a surprise in light of two negative trends that the SAG plan disclosed a year ago -- a 10% decline in employer contributions generated from employment-based earnings; and a 9% hike in healthcare costs.”

Plan administrator Bruce Dow told McNary then that there were three major factors leading to the losses:

  • Increased costs of complying with the new health care reform bill and other governmental regulations
  • The need to divert contributions from the Health Plan to the Pension Plan to improve its funding after the financial market collapse of 2008
  • Reduced employer contributions from SAG's TV work (employers contribute 15% of what a SAG member earns to the Health and Pension Plans)

The Wall Street Journal further quoted Dow as saying:  “Actuaries consulted by the plan determined that equalizing mental-health and substance-abuse coverage would double costs, to north of $3 million annually. That's on top of a deficit expected to be in the tens of millions of dollars in 2011…We're not in a position to afford it.  This is unfortunate because we would have liked to have retained our existing programs."

 

After we opened the Malibu Beach Recovery Center in late 2007, my husband insisted we take SAG Insurance.  Although we are private pay, and count among our clients actors who are able to afford treatment without using their insurance, Oleg wanted to provide working actors who have to use their insurance the same kind of boutique, luxurious setting enjoyed by current film and TV stars.  

Too many actors complained of being sent by the Health Plan’s third party administrator to large institutional treatment centers which dedicate a significant number of beds to convicted criminals and gang members, or mix mental health and substance abuse patients.   Those whose faces and names are familiar to all, even if they did not currently have the money to privately pay for treatment, were terrified that in such settings information about their addiction would surface in the press.  This would not only be embarrassing, but could jeopardize their ability to be insured and bonded by film producers and distributors.

My husband also believed that actors would be particularly in sync with the holistic elements of our treatment program (low glycemic diet, yoga breath work, food supplements).  

Concerns about the Health and Pension Plans were clearly a top priority for the Union during recent contract re- negotiations between SAG and the  Alliance of Motion Picture & Television Producers.  Both SAG and American Federation of Television and Radio Artists (“AFTRA”) received a 10 percent funding increase to their pension and health funds from the Producers, the largest-ever dollar-value bump to these funds; unfortunately the concession was apparently not enough to roll back the Tier II cuts. 

The real solution would be a dramatic change in the U.S. economy, meaning more films and TV series will again be made in this country under SAG jurisdiction, and fewer will be what is known as “runaway productions” (filming non-union or in other countries).  But there are other problems affecting the fiscal health of the SAG Health Plan including TV work shifting to AFTRA, a new provision in the commercials contract that cuts so-called over scale employer contributions for top paid actors, and a 2.5% decline in 2008 due largely to the impact of the Writers Guild strike.

To its credit, SAG has come up with many creative contractual accommodations to allow actors to work legally in productions previously off limits.     

But for now the economy is still floundering and SAG Plan II participants no longer have chemical dependency benefits.  Malibu Beach Recovery Center urges those from the Tier II SAG Health Plan in need of treatment to  call 800 366 8101 to discuss with us some creative financial alternatives.

Anthem Blue Cross: Will the New Management be Consumer Friendly?

Posted by Joan Borsten on July 20, 2010

Duke Helfand reported in the July 20, 2010 edition of the LA Times that the President of Anthem Blue Cross of California,  Leslie Margolin, is stepping down after  California's largest for-profit insurer came  under fire over planned rate hikes of up to 39%.  anthem_blue_cross.LEDE[1].jpg

I am hoping the Times asks Helfland, Scott Glover, Lisa Giron or one of the other dedicated reporters who write on health to investigate the Anthem Blue Cross system for their processing of chemical dependency claims during the two years Margolin was in charge.  

From time to time, we have private-pay clients who are insured through Anthem and want to be reimbursed for what they have paid out for treatment. 

Remember John Grisham’s 1995 novel “The Rainmaker?” Someone at Anthem must have read it for inspiration before designing their claims processing manual.  Unlike Grisham’s fictitious Great Benefit Life Insurance Company, Anthem does not deny each and every benefit, but it is not for lack of trying.  Claimants routinely face an impossible bureaucracy of unhelpful, unfriendly processers whose goal is to delay reimbursement for months or even years.   The goal of the claims representative seems to be wearing the claimant down in hopes he/she will go away. 

At least two of our alumni finally gave up trying to get reimbursed for a benefit they pay for month after month, and allowed Anthem to pocket the money.   Another client had insurance through Blue Cross of Texas.  Because treatment was in California, Blue Cross of Texas was supposed to go through Anthem.  After months of delay, Blue Cross of Texas finally gave up on California and processed the claim themselves.

The successor to Ms. Margolin needs to reform the claims payment system. 

Case in point:

We accept for treatment the wife of a Hollywood Studio Executive.  Let's all her Jane.  The Studio’s chemical dependency benefits are administered by Anthem.  Every moment of Jane’s stay was authorized.  After treatment was completed, Niki, our insurance processor was told to send the claim to a specific address in California.  She did and then was told she had the wrong address.  Turned out she had the right address.  Then the claim was rejected because it needed to be processed by Anthem National.   She sent it to Anthem National which rejected the claim because Malibu Beach Recovery Center is "out of network." Jane has “out of network” benefits.  

90 days after Jane completed treatment, with no payment in sight, I called the Studio to complain.  A few moments later the phone rang and it was a representative of the Anthem National Desk Employer Service who said it was her division that was responsible for paying Jane's claim and would do so right away. 

"Your check will be mailed out this week," she emailed.  "The claim was finalized today.  The check should be issued by Wednesday if not tomorrow.  I will keep you posted.”  

The check finally arrived by snail mail many weeks later.  The total amount of time it took to get paid for authorized treatment:  6 months.

Here's the punch line.  Later we received a letter from Anthem stating we owed them money.  Apparently because we "rushed" Anthem into processing the claim in “just” 6 months, the frazzled workers made a mathematical error in our favor.