By Timothy R. Shannon
The highlight of my time as a student attorney in the Health Law Clinic was helping to secure insurance coverage—and retroactive payments—for my client, who is in long-term recovery from opioid dependency.
My client lost coverage for his much-needed methadone maintenance treatment when his employer switched insurers. This abrupt loss of coverage occurred after the client had been successfully relying on methadone treatment to maintain his sobriety for over 13 years. My client was paying for methadone out of his own pocket, which was so expensive that he likely would have a hard time keeping it up and staying sober.
The client first came to the Health Law Clinic last year distraught and frustrated. The clinic students immediately sprang into action and appealed the denial of coverage. The insurer had recently changed its policy regarding methadone and was scheduled to begin covering the treatment (along with many other Massachusetts insurers). My predecessor student attorney obtained copies of the new policy and re-submitted the claim, which was accepted. This allowed the client to once again begin receiving coverage for his ongoing treatment while the Clinic continued to appeal his case and recuperate his out of pocket expenses.
When I took over the case in September, my task was to convince the insurer to reimburse our client for the costs of his treatment during the gap in coverage. We gathered receipts, as well as affidavits and letters from the client, his providers and others.
In early November, the insurer reversed its denial and granted full reimbursement to my client for all out-of-pocket costs associated with his treatment, while continuing to provide coverage going forward. The client was extremely pleased with the result, as was I. The satisfaction I felt from being able to help my client obtain coverage for the medication he so desperately needed was extraordinary.
Of course, my advocacy on behalf of my client is far from over. The next phase of work on behalf of my client will involve challenging the coverage limitations of the client’s secondary insurer. I am currently forming an argument that will focus on public policy, medical necessity, and violations of Massachusetts and Federal Mental Health Parity laws. If I obtain a victory in this second appeal, it will allow my client to drop his employer-sponsored insurance and save the costs of two premiums each month! Moreover, this appeal might help change the opioid coverage policy for a major Massachusetts health insurer.
Working as a student attorney with the Suffolk Health Law Clinic has honestly been the most educational and rewarding experience of my time here at Suffolk Law School.
Timothy R. Shannon, JD’16, is a Compliance and Monitoring Associate at Affiliated Monitors in Boston, a health care compliance monitoring firm.