The Pendulum Swings Again:
Striking a Balance Between Improving Access and Stopping Bad Actors

By Stacey L. Worthy, Esq.
Over the past decade, great strides have been made to improve access for the treatment of substance use disorders (SUDs), including the enactment of the Affordable Care Act (ACA), which required everyone to have insurance and deemed SUD treatment an essential health benefit, and the Mental Health Parity and Addiction Equity Act, which required insurers to cover SUD treatment on par with coverage of medical/surgical benefits.[1] In fact, three of the nation’s largest insurers announced that they would no longer impose prior authorization requirements on medication-assisted treatment this year.[2]
Yet, some programs have taken advantage of expanded coverage by enrolling individuals in treatment to turn a profit and then leaving them on the streets once insurers stop paying, leading to relapses or worse. Last month (February 2017), a doctor pleaded guilty to sober home fraud, admitting that 90 percent of his patients continually tested positive for illicit substances while in his program, which went ignored while he continued billing.[3]
Third-party payers have responded by taking measures to prevent waste, fraud, and abuse in SUD treatment. However, in doing so, some insurers have back-peddled on progress made. Last year, a California insurer was sued for allegedly withholding payments to SUD treatment programs improperly while it conducted its own fraud investigations.[4] Additionally, patterns of coverage denials are still prevalent, including many Medicaid plans that still impose restrictive practices on SUD treatment.[5]
If the ACA is repealed and replaced, coverage requirements could disappear, reversing progress made over the past seven years. Regulations and policies are needed that allow for access to treatment and identification of bad actors, without punishing those with a legitimate need for treatment. Only then can a proper balance be struck.
In the Third-Party Payer Track at the National Rx Drug Abuse & Heroin Summit on Wednesday, April 19 – “Improving Access and Eliminating Fraud, Waste and Abuse” – a discussion will be held on improving access to treatment. One presentation will give a managed care perspective on improving access to medications for patients with SUDs. Another will lay out why and how to increase access to quality care and cut costs by eliminating waste, fraud and abuse in addiction treatment.
Stacey Worthy is the Executive Director of the Alliance for the Adoption of Innovations in Medicine.