There are alternative accreditations for mental health and substance abuse providers
(for example, CARF accreditation for substance abuse treatment facilities), different
from, for example, the JCAHO accreditations that many hospitals have. These
alternative accreditations are comparable accreditations for the specialty being
practiced. However, not being JCAHO accredited has occasionally been the reason
given for not authorizing behavioral health treatment. This needs to be addressed and
corrected,

It is important that parity extend to all levels of care, including detoxification,
inpatient rehabilitation, residential, partial hospitalization, intensive outpatient, etc.

Parity should extend to court-ordered mental health and substance abuse treatment if
medical necessity criteria are met.

The federal government should create a website, toll-free telephone number, and
outreach campaign to educate consumers about the new parity law and record and
promptly correct any problems consumers may have in accessing services.

In reading about the upcoming parity legislation, I realize that small employers are
exempt from providing this parity of coverage for mental health and substance abuse.
However, considering the fact that prescriptions for mental health conditions are the
number one selling non-generic medications in the US today (3-30-09 Forbes
Magazine), and according to the National Institute of Mental Health, an estimated
26.2 percent of Americans ages 18 and older — about one in four adults — suffer
from a diagnosable mental disorder, perhaps smal! employers should be encouraged
to think carefully about providing mental health/substance abuse parity for their
employees,


Pavillo

Cente for the Treatment of
‘Aconalism and ether Drug Altions

In order to appropriately address any issue concerning the cost and reimbursement of the type of care a patient
would receive at a substance abuse treatment facility such as Pavillon, it may be beneficial for legislators to
know about the care that Pavillon provides, Pavillon is a residential and outpatient provider of treatment for
substance use disorders. The residential program located in Mill Spring, North Carolina, offers treatment for
adults 18 and older who are in need of treatment for alcohol and other drug addictions, and other related
disorders,

Pavillon provides comprehensive, individualized treatment of addiction (alcoholism, drug abuse and other
addictive disorders) and its related medical, psychological, psychiatric, spiritual and related problems.
Pavillon’s treatment model centers on the 12 step recovery process, motivational enhancement and cognitive
behavioral interventions, Our mission is to promote healing and recovery to individuals and families who suffer
from this disease.

Pavillon offers both hospital-based and non-hospital based medical detoxification, as well as our Primary
Treatment program, Our Medical Director is board-certified in Internal Medicine and is also an ASAM and
ABAM diplomate. We offer 24-hour, 7-day a week nursing care. We are a dual-diagnosis facility, capable of
treating both substance and mental health disorders with our highly trained medical, psychiatric, psychological,
counseling and spiritual staff. Pavillon offers a comprehensive series of therapeutic activities, including, but not
limited to individual and group therapy, individualized treatment and continuing care planning, Openness
Groups and Honesty Groups, art and equine therapy, and training in alternative relaxation techniques, such as
yoga and tai chi.

Being very invested in the concept of whole-family treatment, Pavillon offers a quality Family Program and
Children’s Program to provide education and support for family members affected by addiction. We also offer
Intensive Outpatient services and an Extended Care program for professionals.

Pavillon is situated on a beautiful 140-acre campus in the Western North Carolina foothills, with large semi-
private rooms (with bath) overlooking our waterfall and lake. We have a walking trail and a fully equipped
fitness room. We offer chef-prepared meals in a large dining room with an adjoining patio area.

Pavillon’s interest in the well-being of our patients is not just limited to a patient’s time in treatment. We also
provide follow-up with patients at one, three, six, nine and twelve month intervals to determine if the patient is
still abstaining from substance usage. Pavillon alumni meet together in Alumni Support Groups and Aftercare
sessions.

Through all of our programs and services, the underlying theme is continuum of care, for our patients and for
their families,

The following pages are the comments I have asked Betsy L. Beach, Insurance and Medical Records
iftator to submit on\Pavillon’s behalf.

Gx co

CEO

P.O. Box 189 - 241 Pavillon Place - Mill Spring, NC 28756
800-392-4808 — fax-828-694-2321


The comments below are from Betsy L. Beach, Insurance and Medical Records
Coordinator at Pavillon, located in Mill Spring, NC. Betsy holds a BA in
Economics, is certified as a JCAHO accredited coding/billing specialist and has been
with Pavillon three years. Betsy describes many of the flaws in the current system of
providing insurance coverage for care of those recovering from substance abuse and.
mental health issues.

« Behavioral health medical necessity guidelines for mental health and substance abuse
DO vary from plan to plan dependent upon the behavioral health entity that conducts
the pre-authorizations and utilization reviews for the plan. For example, one major
behavioral health entity considers partial hospitalization a higher level of care than
residential treatment, whereas ALL of the other behavioral health entities that
Pavillon works with consider partial a lower level of care than residential. New
legislation should bring ALL behavioral health entities in sync with each other in
terms of how the levels of care within behavioral health are viewed.

Additionally, behavioral health entities vary with the utilization of AXIS versus
ASAM criteria, Uniformity is certainly needed among these entities.

* Medical necessity criteria as it exists currently, actually discriminates against the
somewhat healthy patient who recognizes that s/he has a problem, and who acts
responsibly and seeks treatment immediately. Unless the patient has failed at a lower
level of care, had something other than outpatient providers, or had suicidal or
homicidal ideation or has some type of co-morbidity issue or any combination of the
aforementioned, this patient likely will not qualify for any behavioral health
authorization or any potential insurance reimbursement. The sad truth of the
behavioral health care system today is that the sicker the patient, the better chance the
patient has of authorization and insurance reimbursement. This needs to change in
order to give each patient the care needed at a given time — perhaps this given time is
early in addiction before s/he has had a serious auto accident, a bad fall or even hurt
someone else.

¢ In behavioral health, progress and change is a slower process than hospital stay
progress. And yet behavioral health care entities’ Care Managers conducting pre-
authorizations and utilization reviews often authorize in two and three day
increments, and if SIGNIFICANT change does not occur within that time frame,
continuing authorization is usually denied, Patients dealing with behavioral health
issues are thus again discriminated against when the entire healing process is a very
different one from a hospital stay healing progress.

¢ In behavioral health today, it is as though Care Managers look for any reason they can
find to deny authorization, rather than focusing on the positive progress a patient is
making. Utilization reviews thus become a time of presenting as bleak a picture of
patient progress as possible to ensure continuing authorization of treatment for the
patient. Behavioral health entities should view patient progress more positively. It’s
as though patients are penalized for making clinical progress in terms of behavioral
health issues and this should not be.


When a patient presents to a medical doctor, they can pay their co-payment amount
and be quite assured that their insurance will take care of the rest. In mental health
and substance abuse treatment the patient really has no idea what, if anything, their
insurance will pay, due to the entire medical necessity structure. Disclaimers
routinely quoted by benefits personnel include a statement like “Verification of
benefits does not guarantee claim payment. Payment will be determined when the
claim is received for processing.” If a patient indeed has a behavioral health benefit
on their insurance plan, they should NOT have to be subjected to additional worry
and concern over whether or not they will receive any financial assistance from their
insurance plan. The issues which have prompted their entry into treatment are
significant cause for worry and concern and should not be compounded by behavioral
health being considered the “red-headed step-child” benefit on an insurance plan.
Additionally, a patient’s potential insurance reimbursement for behavioral health
should not be adversely affected by rigid medical necessity guidelines which
“punish” a patient for healing and being healthier.

Many insurance policies’ limitations on the types of facilities covered and the kinds
of clinicians who are allowed to provide treatment often serve to limit a person’s
ability to access mental health and substance abuse treatment.

It is very common to see mental health and substance abuse benefits with a day-limit
per calendar year, or a low-dollar benefit period and/or lifetime maximum. There are
often excessive deductible and out-of-pocket amounts that may further prohibit a
person from pursuing treatment for these disorders. In addition, “allowed amounts” or
“usual and customary rates” upon which benefit payment is based are often
significantly lower than the industry standard, making the patient’s responsibility
much greater.

Parity needs to be imposed even within specific levels of care and their respective
medical necessity criteria. For example, persons who admit with cocaine dependence
are routinely denied inpatient detoxification services due to the fact that withdrawal
from this substances does not pose the physical risk associated with other drugs and
withdrawal. As one Care Manager recently put it, “They’re not going to die from
withdrawal; they just feel like they are.”

Mental health and substance abuse providers are often caught between two evils when
it comes to being either in-network with an insurance plan, or out-of-network. Many
times a lack of any type of out-of-network benefit acts to prevent patients from
seeking providers of specialized services who may not even exist within the confines
of their in-network providers. Out-of-network providers suffer a SIGNIFICANT
decrease in co-insurance percentages, and oftentimes are subjected to higher
deductible and out-of-pocket amounts. While the reasons a provider may choose to
either be in-network or out-of-network vary, oftentimes the right to determine a
provider’s fee for service, and the right to collect the balance of that fee over and
above what insurance pays figure in to the decision. In-network providers suffer as
well, as they are told what they can charge, and are denied the right to balance-bill the
patient. Additionally, insurance companies can, and do, change the rate for what is
considered “usual and customary” and in-network providers have no say in the
matter, Additionally, there is one major insurance plan in this country that is known
to “punish” out-of-network providers by refusing to send any claim payment, under
any circumstance, to an out-of-network provider.