The Fail First Model of Insurance Companies


This story isn’t new. In fact, it is the same story for many people all over the country. And not just people but families. And it looks like this – insurance companies refusing to help families with an addict who needs help.

This story is one of a mother in Staten Island. She looked to her private insurance provider to cover her son’s treatment for a progressive heroin addiction and was constantly denied the help. The paperwork from the insurance company began to accumulate while her son continued to get high. Folders containing denials from her provider, Emblem Health, turned down her 24 year old son, Adama, time and time again. They turned them both down keeping them from getting the kind of care that experts say opioid addicts need to get better.

Months went by while Adam got worse. He stole, he got high, he stole more, he got kicked out his house and eventually was arrested for heroin possession.

“He came home so stoned he couldn’t even stand — I was terrified,” Vicky, a city teacher, said, recalling the first time she learned her son was using heroin. “I called 9-1-1 and they took him into the emergency room, and that’s when I found out he was doing heroin. It was devastating.”

No Long Treatment For You

During that time, Vicky, said her insurance company refused to pay for her son to enter into a long-term residential treatment facility that could greatly improve Adam’s chances of getting better.

Instead the insurance company said they would cover outpatient care—a less intensive level of treatment that allows a patient to stay at home while just seeing a counselor a few days a week. And guess what? For most heroin addicts that isn’t enough.

And Vicky found that out. With opioid addiction, experts say it’s most beneficial if a person acan start in residential treatment and eventually work down to less intensive forms of treatment—not the other way around.

Residential rehab provides 24 hour a day care, usually in a non-hospital setting. Patients are offered a range of substance abuse treatment options over a fixed period of time, lasting anywhere from a month to a year.

And studies show that inpatient care is much more effective than outpatient. 51% vs 36%–in terms of completing treatment, according to a 2011 study in the Journal of Substance Abuse Treatmnt.

Fail First

Still insurance companies are allowed to refuse coverage for inpatient many times embracing a kind of “fail first” model of recovery.

Jacqueline Fiore, executive director of Staten Island YMCA Counseling Service, which provides outpatient services to addicts explained it.

“It’s left up to the provider and the client to prove the need for this level of treatment. Sometimes it is a fail-first model, where you have to fail outpatient visits before you can be approved for inpatient,” Ms. Fiore explained.”For people with this type of addiction, that could very well mean overdose or death,” she said. “A failure could mean death, and that’s the part we’re constantly advocating for change with.”

And the reason is cost.

Luke Nasta, executive director of Camelot Counseling Service, an inpatient facility on Staten Island, says private insurance doesn’t want to cover expenses that come with long-term treatment. “Insurance companies are an industry. It’s a business,” he explained. “They don’t want to spend money if they don’t have to, especially on a problem that is so widespread.” “They’d rather shovel more coin into the vault,” he added.

So basically what they are saying is, “Oh you have cancer, try just taking vitamins for right now and if you’re still alive and that doesn’t work we might cover your chemotherapy.”

Yes, addiction is a disease. Just like cancer. And it is time people began to look at it like that. It is not fair that someone should have to risk death due to their disease because the insurance company is trying to save money. Just as Vicky about it.

So what did happen with Vicky and Adam? Well he went to inpatient treatment and was doing well. That was until his insurance stopped paying, he went home and immediately got high. Vicky is now taking him off  the insurance plan to put him on Medicaid. Why? Because there are more options for Adam that way especially to get into inpatient treatment.

C’mon people. It is time to wake up. People shouldn’t have to die, families shouldn’t have to be torn apart because it costs too much for insurance companies. What do you think?

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