Advocacy

Health Care Services for Conditions Resulting from Patient Behaviors

Adoption Date:
October 1, 1999

Public Policy Statement on Heath Care Services for Conditions Resulting from Patient Behaviors

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Background

Provision of professional health care services involves a therapeutic contract between the patient and the provider. The patient requests services; the provider is available and accessible and willing to provide the services; and a doctor-patient relationship is established, with the patient accepting responsibility for payment of appropriate professional fees for service. Third party payers such as health insurance carriers, are usually involved in the payment of claims for professional health care services rendered.

Health insurers generally define a list of covered services in their insurance contracts and are contractually obligated to pay claims for medically necessary covered services, sometimes based on prior authorization procedures established by the insurer. Insurance contracts negotiated with individual purchasers or with employers who purchase health insurance on behalf of their employees can specify services which are not covered.

There has been a recent and disturbing trend of some insurers to include contract language that states that services are not covered if the health care condition requiring evaluation or management is a medical/surgical condition that has occurred as a direct result of patient behavior which has been defined as undesirable. Examples would be patient behaviors which involve the violation of civil laws. Thus, insurance carriers have at times included language in their contracts that states that evaluation and treatment of injuries incurred in the process of a person engaging in unlawful behavior or the commission of a crime, shall be considered “not covered services” by the third party payer.

Certain health conditions involve disturbances of behavior which are part and parcel of the condition itself. For instance, as a result of the hypersexuality of a state of acute manic-depressive illness, a patient might engage in prostitution, which would be criminal behavior. In the course of that behavior, the patient could contract a sexually transmitted disease. The health insurer could then contend that it has no fiduciary responsibility to pay for health services to diagnose or treat the sexually transmitted disease or its long-term complications.
Another example could be an addictive disorder involving injection drug use. If this injection drug use were to produce an infectious disease such as a cellulitis or an infected heart valve, or were to transmit an infectious disease such as hepatitis or HIV infection, the insurer could contend that such health care conditions were outside the bounds of the contractual liability for payment of the third party payer. Indeed, the insurer might refuse payment for the evaluation and treatment of addictive disorders that involve illegal possession of drugs, the use of prescription drugs obtained by fraudulent means, or the purchase and consumption of alcohol by a minor; or might even refuse payment for injuries incurred in an auto crash while failing to stop at a red light.

It is the position of ASAM that:

1. If an illness or injury warrants medical attention, patients should be able to request professional services from physicians and physicians should be willing to provide appropriate services, regardless of how the illness or injury was initiated.

2. Third party payment for provision of such services should be based upon the diagnosis, the medical necessity for evaluation and management services, and the appropriateness of the services based upon community standards of practice. Payment should not be based upon the behavioral component of the illness. Many health care conditions arise or progress as a direct result of patient behavior, such as eating behaviors, substance use behaviors, or sexual behaviors. The behavioral component of the illness should not be a relevant factor in whether or not insurance coverage is considered appropriate for the condition. Accordingly, coverage for the evaluation and management of substance related disorders should be the same as health insurance coverage for other chronic illnesses.

3. Determination of eligibility for reimbursement for medical services should not be related to whether or not an individual’s behavior falls within a definition of legal behavior established by the criminal code in a given jurisdiction in a given point in time. Whether or not a health care procedure is performed should be a decision between the doctor and the patient based upon medical evidence and community standards of practice. Professional practice standards, not criminal codes, should apply in determining appropriateness.

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