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Medical Necessity

When dealing with third party pay in substance abuse and mental health treatment, one of the biggest misunderstandings we have to address over and over with patients and family members is “My insurance company told me I had 30, 60, 90 days of coverage–why are they denying my treatment now when I’ve only been here 1, 2, or 3 weeks.” Although they do have the coverage, the missing part is what insurance companies call ‘medical necessity’. This is not explained by the insurance customer service representative when they tell you about your coverage. Most insurance companies operate by the following definition of medical necessity:

“Medically Necessary” or “Medical Necessity” shall mean health care services that a medical practitioner, exercising prudent clinical judgment, would provide to a Covered Individual for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the Covered Individual’s illness, injury or disease; and (c) not primarily for the convenience of the Covered Individual, physician, or other health care provider; (d) and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that Covered Individual’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations and the views of Physicians practicing in relevant clinical areas and any other relevant factors.

Medical Necessity criteria are guidelines used by an insurance company’s utilization review or care management staff–licensed registered nurses or licensed behavioral health practitioners. When the clinical information given by the treatment center (La Hacienda) meets these criteria, the cases may then be certified by the utilization review or care manager. When cases do not meet these criteria, they are sent to the insurance company’s psychiatrist reviewer/peer clinical reviewer for an assessment of the case. NOTE: Mental health services cannot be accessed by a policy holder for the sole purpose of avoiding incarceration or to satisfy a programmatic length of stay. These criteria are not meant to be exhaustive and will not cover all clinical situations. Final authorization decisions are made by an insurance company psychiatrist reviewer/peer clinical reviewer after discussion with the treating clinician/physician (i.e. La Hacienda). The reviewing psychiatrist for the insurance company must also always take into account any specific needs of the patient (such as age, co-morbidities, complications, psychosocial situation and progress) or characteristics of the local delivery system (such as the availability of alternative levels of care) when applying the medical necessity criteria. Variations in the availability of services in different geographic and regional areas are also considered. If an indicated service is not available within the patient’s community at the level of service indicated by the criteria, authorization may be given for those services at the next highest available level.

The following are the levels of care for the treatment of chemical dependency and the medical necessity continuum of care:

1. Detoxification – Patient has high potential for withdrawal, requires medical management of symptoms, 24 hr. nursing, daily doctor visits. La Hacienda provides this level of care.

2. Inpatient Rehabilitation – Patient has medical or psych-related issues that require 24 hr medical monitoring by nursing and daily doctor visits. La Hacienda provides this level of care.

3. Residential Treatment Center (RTC) – 24 hr. supervised living environment, no withdrawal symptoms, required doctor visit once weekly or as needed. These are considered long term programs. La Hacienda does not provide this level of care.

4. Partial Hospital Program (PHP) – also called “Day Treatment”. This is a medically monitored outpatient level of care providing 6 to 8 hours of service daily. The patient usually sleeps at home. La Hacienda provides this level of care with free boarding due to the location of the facility.

5. Intensive Outpatient (IOP) – This is a non-medically monitored outpatient level of care. Groups typically meet 3 to 4 nights a week for 3 to 4 hours, averaging 10 hours per week. An abuse diagnosis can qualify a patient for treatment at an IOP level of care. La Hacienda provides this level of care.

6. Outpatient Therapy – The patient meets with a therapist, as necessary, usually in an office setting once a week, every two weeks, monthly as determined by counselor and patient. La Hacienda does not provide this level of care.

In conclusion, it is not that the insurance company is denying treatment; instead they are denying a level of care because the patient does not meet medical necessity.