Doctors, hospitals fight denial of substance-use claims


At Vanderbilt University Medical Center, up to 35 percent of trauma victims come in with alcohol or drugs in their system at the time of an accident.

Under state law, insurers can deny payment of those medical claims, something that doctors and hospitals argue not only costs them money but also could serve as a disincentive to screening patients for drug and alcohol.

Hospitals and doctors want to be paid when they provide medical care, no matter the condition of the accident victim.

Last year, state lawmakers passed a resolution requesting a review of Tennessee’s alcohol and drug laws. They’re due to receive a report by Dec. 1.

Hospitals and doctors say not all insurers block claims tied to a victim’s substance use. But at Vanderbilt, insurers recently denied two claims linked to substance abuse that were worth more than $300,000 combined, said Bryon Pickard, director of operations for Vanderbilt Medical Group, a practice of 1,400 physicians and other providers.

If insurers don’t pay, often patients don’t have the money to pay either, and the shortfall adds to hospitals’ uncollectible accounts or taxpayers eventually cover costs through programs such as Medicaid.

Other states study issueColorado, Connecticut, Illinois, Indiana, Iowa, Maine, Maryland, Nevada, North Carolina, Oregon, Rhode Island, South Dakota, Washington and the District of Columbia prohibit insurers from using intoxication to deny claims.

Screening emergency patients for alcohol and drug problems and offering brief counseling could save Tennessee businesses and residents $245 million a year in extra health-care expenses, according to Ensuring Solutions to Alcohol Problems, a project at George Washington University Medical Center in Washington, D.C.

Not all insurers deny claims under Tennessee’s law.

BlueCross BlueShield of Tennessee, the state’s largest health insurer, said it doesn’t deny claims based on intoxication and as of September will end a policy under which it could deny claims related to an injured person taking part in a felony, an attempted felony, a riot or insurrection.

Insurer Aetna said it doesn’t deny payments because of intoxication, but might seek restitution from the person who caused the accident. UnitedHealthcare said that it doesn’t have and doesn’t contemplate having such language in its contracts.

Jim Walker, president of Individual HealthCare Specialist Inc., an insurance broker in Brentwood, said most insurers cover such incidents but deny payments if a person misrepresented an alcohol or drug problem when signing up for a policy.

Dr. Julie Dunn, director of trauma with Johnson City Medical Center in East Tennessee, however, said the practice remains an issue. The trauma center she runs stopped taking alcohol and urine samples as drug screens after an insurer refused to pay the claims of a man who became a quadriplegic after a fall at home related to drinking several bottles of beer.

“It’s not in anybody’s best interest” to deny such a claim, Dunn said.

Getahn Ward covers the business of health care. He can be reached at 726-5968 or at

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