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Insurers must be prominent among those responding to the opioid crisis

The opioid crisis demands cooperation from many partners, especially from health insurers that have the power to help those suffering.

But a recent News article tells the alarming story of families whose loved ones had been denied coverage. The result can be harmful, or even deadly.

When parents, some of them elderly, are willing to speak out in an effort to help others struggling through the system, that’s evidence of a problem.

There have been reports of health insurers denying services to those struggling to break from an opioid addiction, or the heroin habit that got picked up because it’s cheaper than the prescription painkillers.

News staff reporter Lou Michel cited a state attorney general’s report from 2015. “Excellus Health Plan, based in Rochester, improperly denied 2,700 claims between 2011 and 2014, including several dozen from Univera Healthcare,” including those seeking care for inpatient drug treatment and eating disorders.

The company has been ordered to pay $500,000 in restitution and provide 2,700 customers with the opportunity to appeal denials for inpatient substance abuse disorders and eating disorders. The restitution process has resulted in only 10 members who have been reimbursed to date, for a total of $55,000.

Univera had 59 customers eligible for appeal, yet only one pursued restitution. The denial was reviewed and upheld by a state-assigned independent review agent, according to an Excellus official.

There have been others across the state ordered to reimburse $1 million-plus for denying treatment that members paid for themselves.

As Michel wrote, state officials say that penalties are part of our process to ensure health insurers obey the state laws. Restitution cannot come soon enough for families that have already spent a good deal of their own money.

Insurers insist that decisions are based on an individual’s needs and not the costs. They say they are doing everything they can to help those enrolled. But what should families do when help is denied?

Consider the stories of Judy Capodicasa and Colleen Frey, widows in their late 70s. Both are worried about sons dependent upon Suboxone, a prescription medication that reduces the urge for heroin and other opioids.

Capodicasa, 77, says a pharmacist last month let her 48-year-old son, a recovering heroin addict, know that his Medicaid-managed health care plan had stopped paying for his Suboxone.

Frey, 79, said her 46-year-old son is expected to soon lose his Suboxone prescription. His doctor notified him that his insurance would stop paying as of June 1. The reason, Frey said, is because the doctor has not renewed its contract with Medicare, which her son uses because he is disabled. His addiction to prescription opioid painkillers began when he was treated for an autoimmune disease that calcified his joints.

Health insurers insist they have made efforts to ensure patients receive care. However, there is recourse for families that believe they were treated unfairly.

State Attorney General Eric T. Schneiderman issued an alert to state residents to call a special help line if they need it while attempting to get drug and mental health treatment through health insurers. The attorney general’s “Health Care Helpline” number is 800-428-9071.

The opioid epidemic is ravaging communities. A News map shows the devastation by ZIP code. The governor recently announced the formation of a statewide Heroin Task Force, which will develop a comprehensive plan aimed at ending the epidemic in New York.

Everyone has a role in dealing with this crisis, from family to community to elected officials and health insurers. It is about saving lives.