Navigating The Maze of Insurance Coverage For Addiction Treatment

Navigating the maze of health insurance coverage can be a real challenge. For people with addiction or other behavioral health conditions, the process of getting treatment approved and paid for by health insurance providers can be overwhelming. Unfortunately, many people who need addiction treatment give up when their health insurance company denies the funding for most of it.   Mark Gerges, M.D., is the director of utilization review at Lakeview Health. His team works hard to get Lakeview patients the insurance coverage to which they are entitled. “Many insurance providers want to treat as little as possible,” he says. “Carriers are usually prepared to pay for detox. The challenges appear at certain levels of residential treatment.   But that’s when patients are actually working on the psychological foundations of their substance use disorder following the strictly medical component of addiction treatment. My team provides insurance companies with continuously updated information so that they will authorize as many days of residential treatment as are needed by the patient to begin a sustained recovery.”   In order to be able to provide the correct information, Lakeview Health needs the help of the patients. Jessica Aaronson works in the Intake Services department and is often one of the first people that patients or their loved ones talk to.   “I try to get as much information about potential patients as possible,” says Aaronson. “In order to help them, we need to know what substance they are struggling with, what other behavioral health conditions—if any—play a role, and what kind of medical insurance they have.”   Lakeview Health works with many major health insurance providers, and our intake specialists will do everything they can to make the health insurance verification process as straightforward and stress-free as possible.   It is important to get accurate information about the drug and alcohol use because it will determine what kind of coverage is available. Addiction treatment for alcohol use disorder differs from treatment for opioid use disorder, which will be reflected in the coverage insurance companies provide. How frequently was the substance used and at what doses? Were multiple substances misused? Are there co-occurring medical or behavioral health issues? The answers to those questions will determine how Lakeview is able to present the case to the insurance provider.  

Skilled Presentation

  Fortunately, potential clients and patients of Lakeview Health have a highly qualified team on their side. Dr. Gerges leads a team of medical doctors that brings a lot of experience with addiction and other medical conditions to the task at hand.   “We picture every patient as a story,” says Gerges. “That story starts when they call in. We get a detailed record of that call. We use our medical background to study all the lab work, check any medication they may be taking, and any other relevant information from their medical record.”   “How we present the story of that human being suffering from a substance use disorder is an important part of the insurance provider’s decision on how many days of treatment they will authorize,” says Gerges. “Everything we say is accurate, but a convincing presentation is crucial. It’s a skill our team has acquired and refined over time. Our medical expertise certainly makes a difference.”   If you are not sure what your insurance plan covers, there is no need to worry. Lakeview Health can find out for you. “We call insurance companies to verify coverage, what deductibles apply, and what the maximum amount out of pocket would be,” says Aaronson. “All you have to do is call us.”   “If Lakeview Health is not a good fit for a patient, we will find somebody else who can help,” says Dr. Gerges. “For example, we don’t take Medicaid, but we can refer Medicaid patients to the right place to get help. No one goes uncared for.”    

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