Kenneth Blum, Ph.D. and Joan Borsten

American insurance companies

There are approximately 14,500 clinics and programs in America that provide treatment for all types of addictive behaviors we call “Reward Deficiency Syndrome (RDS)”. While most of these have good intentions to provide needed help to the victims of RDS, we propose herein that most of their efforts, especially during periods of aftercare, are not based on the existing scientific evidence. One important barrier to treatment relates to potential fraud on the part of insurance companies. If we consider addiction for both drug and non-drug related to be a brain disorder as espoused by the American Society of Addiction Medicine (ASAM), with genetic and epigenetic impairments, how could it be fixed in weeks or months, let alone in 7-30 days? Without considering genetic predisposition as a factor, evidence emerging from neuroscience now suggests that it will take at least 3 years for the brain to heal in heavily addicted opiate/opioid patients.

For example, neuroimaging studies clearly show that in abstinent heroin addicts there is a protracted reduction of resting state functional connectivity (where one brain region cross talks with
a distant brain region) particularly in an important network that includes: dorsal anterior cingulate, medial frontal gyrus, nucleus accumbens, posterior cingulate, occipital cortical areas, and cerebellum. These facts will promote the “revolving door” and relapse. We also now know that certain genetic variations such as individuals that carry the A1 form of the dopamine D2 receptor gene will have 30-40 % less D2 receptors and as such will have a high risk for relapse, hospitalization and even fatality. It is noteworthy, that over 100 million people in the United States alone, carries this gene form.

Our basic tenant is that the majority of people entering an addiction treatment facility, possess a hypodopaminergic trait (genetic) and/or state (epigenetic) which is critical in terms of continued motivation to use/abuse of alcohol or other drugs and certain addictive behaviors ( e.g. gaming, food, sex etc.) and can lead
to relapse. Refusing intensive treatment for all RDS behaviors is tantamount to refusing treatment for other inheritable disorders like diabetes and cancer.

History of Parity Laws for Mental Health
We would like to point out the brief history of the Parity laws governing health care in the United States as it pertains to addiction. It is noteworthy, that in the 70s and even 80s many employers argued against mental health benefits for Substance Use Disorder (SUD) under the Employee Retirement Income Security Act of 1974 (ERISA). Not until 1994 did the Clinton administration propose that Mental Health and SUD services are to be fully integrated into health alliances. This was countered by others suggesting (1) the health plans had the ability to manage the benefit so as to alter patterns of use; (2) a payment system for health plans that addresses biased selection; and (3) preservation of the existing public investment while accommodating in a fair manner differences in funding across the fifty states. In 1996, the Mental Health Parity Act required employers and insurers offering mental health benefits to raise dollar coverage limits on mental health services to the level of surgery and major medical services. In 2012, Kennison Roy and other ASAM physicians helped form stronger Parity laws specific to change the practice activities of addiction physicians, addiction therapists, addiction counselors and addiction nurses, as well as the activities of administrators and service delivery financial personnel. In 2014, T.D. Molfenter pointed out that The Patient Protection and Affordable Care Act (PPACA) would significantly alter addiction treatment service delivery.

Are we facing Fraud by The American Insurance Companies?
Mental Health, which includes SUD, may have finally obtained parity with surgery and major medical, but for the most part American insurance companies still do not understand addiction. Five years after ASAM redefined addiction as a chronic brain disease the United Behavioral Health telephone prompt says: “If you are calling about substance abuse say ‘behavioral.’”

Parity violations abound. The Office of the New York Attorney General, a national leader in enforcement of the Mental Health Parity and Addiction Equity Act of 2008, has already successfully prosecuted at least five cases against health insurance companies that failed to cover residential treatment, improperly evaluated claims, denied medical necessity more frequently than major medical, or charged higher co-payments for outpatient visits. Some of the insurance companies were forced to recalculate years of previously paid claims determined by the Office of the NY Attorney General, to most probably been underpaid.

It was the NY Attorney General that sued all of the major insurance companies in 2009 for using Ingenix, a corrupt re-pricing database owned by United Health Care. Ingenix regularly underpaid out-of-network providers their Usual, Reasonable and Customary (UCR) rates. The providers then balance billed New York consumers for the difference. Attorney General Cuomo determined that the insurance companies and Ingenix had bilked his constituents out of millions of dollars. A subsequent investigation by the Commerce Committee of the U.S. Senate determined that consumers across the country had been bilked out of billions. Cuomo used the 2009 settlement monies to create Fair Health, a non-profit data base for determining UCR rates for out-of-network providers.

Six years later all of the major insurance companies were again using Ingenix-style for profit “UCR cost containment” vendors. This time four of the most prominent vendors, each with different “branding,” are actually owned by the same New York-based parent: Multiplan. On April 3, 2012, NY Attorney General Eric T. Schneiderman pointed his finger at Viant, one of the Multiplan companies, for illegally re-pricing Oxford Insurance claims from out-of-network providers who were not contracted with them. Three months later Schneiderman found that another Multiplan’s Data ISight was underpaying out-of-network providers who then balanced billed members of AXA Equitable Life Insurance’s employee health plan.

California is now seeing the same violations of mental health parity that have been investigated by the NY Attorney General’s Office plus late payments, robo-signed denials of payment for lack of medical necessity, fail first protocols, likelihood of improvement requirements, denial of treatment because of patient non-compliance, and limits to the scope or duration of benefits for services provided under the plan or coverage. Additionally, as the major insurance companies don’t like paying for effective addiction treatment, they are using companies owned by Multiplan to re-price California’s small non-medical treatment facilities using irrelevant data from Medicare.

Creative cost containment vendors help their clients avoid paying the established UCR rate of Malibu’s 42 treatment centers by expanding the Malibu’s 90265 zip code 90265 to 902xx. This allows them to pit 200 Malibu and Beverly Hills high-end facilities against 200 low-end non profits facilities in some of Los Angeles’ most low income, crime-ridden areas, including 100 free Salvation Army beds.

It is Health Net, however, which has taken the lead in trying to destroy effective substance abuse treatment. From January 2014, when Health Net began offering individual PPO policies through Covered California, until February 2016 Health Net was hailed by the addiction treatment industry for offering long-term substance abuse benefits that actually made a difference. It was surprising as Health Net had a history of being a bad player. In 2007, a New Jersey federal judge fined Health Net for obstructing justice in a case related to Health Net’s use of Ingenix. In 2008, Judge Faith S. Hochberg agreed to accept a settlement that required Health Net to pay a quarter of a billion dollars to the insured they had cheated.

Last fall, in order to merge with the St. Louis Missouri Medicaid company Centene, Health Net defied Judge Hochberg’s decision. Declaring wide spread fraud on January 8, 2016 Health Net launched a dragnet audit of all out of network treatment facilities in five states. Most facilities were not paid for 4th quarter 2015 claims, and 1st and 2nd quarter 2016 claims until July 2016. Health Net, which had previously paid 75% of billed, began by trying to pay Medicaid rates of less than $200/day or inpatient and less than $100/day for outpatient. After protests, Health Net settled on 190% of Medicare although at least 30 months of benefit checks have stated repeatedly that there was no linkage to Medicare fee schedules. Several Appellate California court decisions confirm that providers have a right to depend on information provided in a telephonic benefit check. Health Net also violated several requirements of parity, issuing thousands of cut and pasted denials for lack of medical coverage robo signed by Dr. Matthew Wong, a Health Net Medical Director whose addiction credentials Health Net has refused to provide.

The California Department of Insurance launched an investigation in April 2016 into the illegality of Health Net’s actions, but had not made a determination by early August causing treatment facilities struggling to survive financially to sue Health Net in large multi-plaintiff actions. A similar action was filed by Arizona facilities in late July.

Dopamine Homeostasis “Aftercare” –A Long Term Goal to Prevent Relapse and Enhance Recovery Quality
We use “aftercare” to refer to any form of program or therapy following primary treatment including 12-Step programs. Unfortunately, very few programs actually provide any evidenced-based treatment approaches during this most vulnerable period in recovery. While there is evidence for the approved FDA drugs to treat drug addiction (e.g. alcohol, opiates, nicotine) these drugs favor a short-term benefit by blocking dopamine. We argue instead for the utilization of long-term benefits that induce “dopamine homeostasis”, or in simpler terms “normalcy.” We suggest that this could be accomplished through a number of holistic modalities including, but not limited to, dopamine-boosting diets, hyper-oxygenation, heavy metal detoxification, exercise, mindfulness, meditation, yoga, brain spotting, cognitive behavioral therapy, trauma therapy, and most importantly, brain neurotransmitter balancing with nutraceuticals such as KB220 variants. We embrace 12-step programs and fellowships but not as a stand-alone modality, especially during aftercare. It is imperative that clinical professionals begin to understand resting state functional connectivity (rsfMRI) as being one important cornerstone in terms of how to treat RDS.

Insurance companies should begin to realize that like cancer, intensive care, treatment and most importantly prevention tactics are beneficial in the long-term for reducing relapse and as such, could actually lower their cost. Drugs, food, smoking, gambling, compulsive sexual behavior and even major depressive disorder (MDD) have been shown in many studies to reduce resting state functional connectivity [rsfMRI]. Understanding this we postulate any modalities that can restore this impaired cross talk between various brain regions (e.g. nucleus accumbens, cingulate gyrus, hippocampus etc.) should be incorporated into the aftercare plan in all treatment programs in America.

While this is a laudable goal anything less will ultimately lead to the so called “revolving door” for as many as 90% of treatment participants. “Love needs care” and it must start with the gate keepers of treatment- the insurance companies. Finally, our unique challenge is to re-educate the top decision makers in the insurance world. Instead of threats related to possible criminal action- provide a new guidance that reflects the real facts. The insurance companies should understand the etiological factors linked to Reward Deficiency Syndrome as a biological based disorder/disease and if genetic it should be on the same level as Diabetes, which could be life-long not just 7 days of detoxification.

The smart insurance executives will heed these remarks and adopt a new approach embracing Parity laws and understanding a plausible preventive tactic reducing long-term costs and instead of being chastised become a hero!

Kenneth Blum, B.Sc. (Pharmacy), M.Sc., Ph.D. & DHL; received his Ph.D. in Neuropharmacology from New York Medical College and graduated from Columbia University and New Jersey College of Medicine. He also received a doctor of humane letters from Saint Martin’s University Lacey, WA. He has published more than 550 abstracts; peer-reviewed articles and 14-books.

In 2007 Joan co-founded Malibu Beach Recovery Center which became famous for its neuroscience based alcohol and drug treatment program. While serving as CEO, she used the skills learned as a journalist to advocate for the addiction community
in Sacramento and Washington, D.C. After selling Malibu Beach Recovery Center she continued her advocacy efforts and recently, in response to efforts by insurance companies to damage California’s addiction treatment industry, she co-founded the Addiction Treatment Advocacy Coalition (ATAC). ATAC provides political and legal advocacy, education and consumer protection in the field of addiction treatment