Cigna Drops Pre-Authorizations for Opioid Addiction Treatment

What Happened?

In late October, 2016, Cigna insurance company changed their policy. Previously, Cigna, like most other insurance companies, require a pre-authorization before approving a patient for treatment for addiction.

Why Did This Happen?

As opioid addiction is a growing problem in the United States, the need for treatment is also growing. This is because many physicians continue to prescribe opioids for pain without realizing they are feeding their patient’s addiction or without realizing that their patient may be selling or trading these pills, which allows them to be fairly easily obtained by those who are struggling with opioid addiction. Previous Cigna patients (and most other patients with other insurance carriers) would go into the hospital; either on their own or via ambulance after a drug interaction or overdose, and the medical treatment team would recognize the patient’s need for opioid addiction treatment. At that point, the medical facility would request approval for the treatment protocol through their billing department. The billing department would then contact the insurance company and provide the information necessary for the insurance company to decide whether the patient’s need actually required opioid addiction treatment and they would then decide whether to approve the treatment plan.

In the best case scenario, this process could take hours. In some situations, busy offices, lost paperwork, or other problems could result in several days of waiting for approval. In addition, if the insurance company did not see enough reason to approve the treatment, they would deny the request. This would either force the treatment team to gather new or additional information and re-apply for the patient’s treatment approval or they would need to discharge the patient without the treatment, knowing the patient would likely return due to another overdose or other side effects of opioid drug use.

Too often, when a patient is discharged without the addiction treatment experience, they return to using opioids. This can lead to poor decisions or dangerous experiences during their drug use, or to overdose and death. Either way, the person’s lack of immediate treatment is only detrimental to them. Not only can it provide additional time for them to return to their addictive behaviors, it can also hinder their ability to qualify to receive treatment quickly because treatment facilities are severely lacking in numbers, though the numbers of patients in need is growing rapidly. This means that there are rarely enough beds in opioid treatment facilities for everyone struggling with addiction. Often, the beds are first come, first serve, which means that any patient who is waiting for insurance pre-authorization is at risk of not having a bed in a facility once the authorization comes through.

This means that those with quicker pre-approval processes in their insurance companies, those who get lucky in having a speedy pre-approval process, and those who can afford to pay out of pocket are much more likely to receive treatment by not having to wait in the lengthy lines for an available bed. Since this is typically an experience reserved for those with money or those who come from families with the money to pay for such treatment, the detriments are much more likely to occur for those patients who lack financial resources. Some see this as a sad reality where others see this as a way in which poorer Americans suffer and may be kept in an addictive state unnecessarily, leading to the increased likelihood of the death of those who cannot afford the expensive opioid addiction treatment without their insurance company’s approval.

In addition, it can cause hospitals and emergency facilities to consistently be treating the same patients, who take medical resources, as well as costing insurance companies billions of dollars each year.

What Happens Next?

It is unknown whether other insurance companies will follow Cigna’s lead; however it is highly likely that the other insurance companies are watching the outcome of Cigna’s policy change, as well as their number of insurance policy holders. Insurance companies primarily want to make money, so if they are seeing a drop in their own clients due to clients moving onto Cigna policies, they may consider the idea of adapting their own policies in order to prevent additional clients from leaving. In addition, they, like many within the addiction care field are likely to be watching to see whether this change leads to additional treatment program usage and to a decline in situations where people with addiction issues are dying or are relapsing. Cigna will likely also be measuring these events, as well as keeping an eye on how often someone is quickly admitted to addiction treatment facilities, in order to ascertain whether the change in policy makes financial sense to them, as well as whether it is a policy they should both continue and promote as a selling point for their company.1-7

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