Executive Summary
Please see the denial rates for 20 psychiatrists and family doctors who were hired by insurance companies, to do peer-to-peer reviews about addiction treatment in California from November 2021 through July 30, 2022. The information was gathered by 58 California treatment centers. Please note that not a single one of the doctors hired by the insurance companies is a qualified addiction doctor. According to California law, such reviews must be made based on American Society of Addiction Medicine criteria - all six criteria. That is not being done, and so substance use patients are being sent home prematurely. We need to stop this.
Why SB 999?
INTRODUCTION
SB 999 was written to out an end to a decade of yet another outrageous and harmful health insurance industry practice in California.
WHAT IS WRONG
We in the industry know that it takes at least 28 days of detox combined with 24/7 residential care, to restore the brain to a state where it can again begin to function without alcohol, prescription drugs or street drugs. Treatment is costly so the insurance companies try to authorize a minimum number of days of up front and then send unqualified doctors to do so-called “peer-to-peer” reviews in order to deny the additional days of treatment requested by an addiction doctor using ASAM criteria. A high percentage are “external” doctors hired from companies like Prest & Associates of Wisconsin who deny 50-100% of the reviews they are sent much like Dr. Jack who, as reported by 60 Minutes in 2014, support themselves or augment their incomes by doing multiple well-paying denials each day.
WHAT IS ASAM CRITERIA?
ASAM Criteria is a strength-based, multidimensional assessment that addresses an addiction patient’s needs, obstacles, and liabilities, as well as the patient’s strengths, assets, resources and support structure, in order to determine the appropriate level of treatment along the continuum of care (from the various levels of outpatient to residential/inpatient services to medically managed intensive inpatient services). It has been developed over many years.
