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Changes in Insurance Reimbursement Hit People in Recovery Hardest

By Eve Pearce

Blue Cross/Blue Shield’s new policy, which came into effect as of October 14, 2012, is posing quite a challenge for patients, health care providers, and laboratories working to prevent and treat addiction. In the past, the BlueCard program allowed patients who were beneficiaries of any regional Blue Cross/Blue Shield (BCBS) plan, to receive health care from providers and hospitals in other states and regions. The new policy significantly alters this simple and efficient process.  Laboratories performing drug tests are now required to bill the BCBS plan of the region where the patient’s specimen was taken, instead of their own regional BCBS plan, if these respective regions are different. The differences can be gleaned from the following table:

Prior BlueCard Policy Current BlueCard Policy
* A BCBS patient from New York traveled and had a lab test performed in Delaware. * A BCBS patient from New York travels and has a lab test performed in Delaware.
* The specimen was collected in Delaware and the lab test was performed in Maryland. The Maryland lab sent the claim to their local BCBS Regional Plan in Maryland. * The specimen is collected in Delaware and the lab test was performed in Maryland. The Maryland lab no longer has a right to forward the claim to the BCBS plan in Maryland.
* The Maryland BCBS calculated the reimbursement amount to be received by the Maryland lab at the ‘in-network rate’, based on the lab’s provider status and home plan. * The Maryland lab must obtain a record of where the specimen was obtained.
* The Maryland lab was directly reimbursed by the Maryland BCBS. * The Maryland lab must submit the claim to the BCBS plan in Delaware, since the specimen was drawn there.
* BCBS patient only had to pay minimal out-of-pocket costs for availing of the nation-wide BCBS network. * The BCBS plan in Delaware will issue the reimbursement at the ‘out-of-network’ rate. The patient has to pay higher out-of-pocket costs.
* The patient’s BlueCard benefit allowed him or her to avail of ‘in-network’ services anywhere in the USA. * The patient receives the lab test payment check from the BCBS plan. The Maryland lab, which performed the test, now has to pursue the patient for payment.

By focusing on where the sample was taken, rather than where the test was performed, BCBS is treating claims by labs located in regions or states other than the region or state where the specimen was taken, as out-of-network claims. Given that patients are paid directly, laboratories are faced with the difficult task of obtaining payment directly from the patient (collection success rates are as low as 50 per cent).

Patients in general who receive direct reimbursements are now at risk of committing insurance fraud when they use the funds for any reason other than paying the laboratory the amount owned. Also vulnerable are those who actually decide to pay the costs incurred by the laboratory, yet are forced to outlay significantly more than when the service is performed by an ‘in-network lab’.

People with Addiction Among the Hardest Hit

People in recovery who suddenly find themselves with money to burn are threatened by relapse.  It is easy to appreciate that finding a check for $47 in the mail when one may be experiencing withdrawal symptoms or cravings could weaken one’s resolve.  Drugs cause changes in the way the brains of people with addiction work, making them susceptible to triggering mechanisms. Money in the hand can likewise reduce the efficiency of behavioral therapy, considered highly effective in the treatment of drug addiction. According to Casa Nuevo Vida, an organization listed in kwikmed.org’s list, 20 Exceptional Alcohol Addiction Resources, the goal of behavioral therapies in addiction treatment is to help the patient stop using substances “by modifying conditions under which a response produces a consequence.” There are three important components of behavioral therapy: rewarding behavior not associated with substance use, tying substance use with its unpleasant consequences, and lastly, removing triggers that can instigate use. The third component is often compromised by money worries or a sudden windfall.  It is for this reason that people in recovery often use prepaid debit cards that cannot be used at an ATM machine, to get cash back at a store, or at bars, liquor stores, or casinos.

Short-Term Profit Versus Long-Term Health

According to the National Institute on Drug Abuse (NIDA), the cost of drug addiction in the U.S. amounts to over $600 billion a year in health care, law enforcement, subsidized treatment, prevention and more. The new BCBS policy may have reduced the insurer’s costs in the short term by effectively eliminating ‘out-of-network’ providers, yet in the long run, insurers will pay a heftier price for increased overdoses, emergency visits, hospitalization, and drug treatment costs resulting from this short-sighted approach.

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