Harry NelsonHarry Nelson is quoted in a story published by Behavioral Healthcare concerning the recent investigation opened by Health Net, one of the largest health plans in California. The case has generated attention because of the number of providers who received a demand for records, together with a suspension of payments. Health Net, which is in the process of merging with Centene, is one of the six largest health plans in California, along with Blue Shield of California, Anthem Blue Cross, United Healthcare, Aetna, and Cigna. All health plans have been required to add coverage for substance abuse treatment into their plans based, among other things on the “minimum essential coverage” requirements of the Affordable Care Act, and all have experienced significant claims expenses as a result. The tension between surging demand for addiction treatment and increasingly aggressive insurer cost control efforts translates into continued conflict around reimbursement compliance efforts.

The article describes the conflict between insurers and providers over patient financial responsibility. While health plans routinely accuse healthcare providers of fraud when patients do not pay their share of costs (through deductibles, copayments, and coinsurance), Nelson disagrees with the allegation, noting that, in some circumstances, providers may legitimately discount share of cost “such as when patients are genuinely unable to pay.” While the issue of patient financial responsibility has been a perennial point of dispute between healthcare providers and health plans, the Health Net case is only one many examples of how this issue is increasingly coming to the fore of late.

For more information about reimbursement compliance in addiction treatment, contact Nelson Hardiman at info@nelsonhardiman.com.