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.

The doctors who do “peer-to-peer” reviews for addiction are for the most part psychiatrists and sometimes family medicine doctors.  Fifty-one California state-licensed addiction treatment centers began keeping score in November 2021, logging the results of each “peer-to-peer” reviews and details about the reviewers.  Despite a California workers comp scandal several years ago, which revealed Anthem was hiring doctors who had lost their medical licenses, were paying other doctors to do the “gig”, or on probation, doctors and certain companies that provide “experts” often refuse to provide the doctor’s full name or medical background or state license numbers.

Although addiction is a chronic brain disease, with unique treatment dimensions, none of these doctors whose names and denial rates appear on the “California Scorecard” are currently practicing addiction medicine and certified by ASAM.   These doctors usually devote no more than 5-10 minutes discussing the case with an addiction specialist.  They like to say they know ASAM, which is a multidimensional assessment tool, but cherry pick which of the six criteria the patient satisfies in order to deny.  Many patients are aware that they are not yet ready to step down to the outpatient level of care and privately pay for the denied days (which then have to be overturned in order to be reimbursed).  Often the facility agrees to appeal and provides what they hope will be a temporary scholarship.  Meanwhile all external doctors who deny reportedly get paid handsomely, and the insurance company saves the cost of treatment. It is possible the internal insurance company doctors who deny are also compensated.

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