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An emerging therapy method for troubled teens is gaining acceptance in the medical community, and both insurers and plaintiffs’ attorneys are taking notice.
Outdoor behavioral therapy—often dubbed “wilderness therapy"—seeks to treat young people with behavioral or substance abuse issues by combining traditional therapy methods with outdoor activities such as hiking and camping. With price tags that can top $500 per day for weeks- or months-long treks, many of these programs used to be largely out of reach for all but the wealthiest families. That’s beginning to change, thanks to a recent shift in federal law, emerging research and a handful of dedicated attorneys and advocates.
The legal shift stems from a 2008 federal law forcing health plans that cover mental health or substance abuse treatments to provide those benefits on the same terms that apply to medical and surgical benefits. The Affordable Care Act later extended these mental health parity requirements to a larger universe of health plans.
Before these changes, insurance coverage for wilderness therapy was limited and lawsuits over coverage denials were largely nonexistent. Since the final mental health parity regulations became effective in 2014, about 20 lawsuits have targeted insurers that deny coverage for wilderness therapy. In the past year, proposed class actions have been filed against Cigna Corp., Oxford Health Insurance, Empire HealthChoice Assurance and Blue Cross Blue Shield of Massachusetts. Those cases are ongoing, and Anthem Health Plans of Kentucky privately settled a similar lawsuit in December.
Wilderness therapy programs vary in duration and intensity. In general, most licensed and accredited programs combine traditional mental health treatments—such as individual and group therapy sessions led by licensed counselors—with outdoor and physical activities that are thought to have therapeutic value. Activities can include hiking, camping and learning to prepare food and build shelter in the wilderness, which proponents say foster feelings of group cooperation, communication and personal significance.
“It’s not a bunch of kids singing Kumbaya around a campfire, and it’s not some sort of catered dude ranch situation,” Jordan Lewis, a Fort Lauderdale, Fla.-based attorney who represents patients seeking coverage for wilderness therapy in several recently filed class actions, told Bloomberg BNA. “It’s a conventional therapy performed in an unconventional setting.”
The adolescents and young adults who participate in wilderness therapy often have a combination of behavioral, mood or substance abuse issues—including, in some cases, video game addictions—and they can remain in the programs for six to 12 weeks or longer. More than 5,000 young people participate in wilderness programs each year, according to 2012 research by Michael A. Gass of the University of New Hampshire.
Gass told Bloomberg BNA that research on wilderness therapy has “greatly validated” the practice over the past five years.
“It used to be that the field of wilderness therapy didn’t really have a defensible position,” Gass said. “People wanted to know—is it safe, does it work, how do you tell a good program from a bad program, and is it worth the money. Five to 10 years ago, the field did not have its research position to answer those questions. Now it does have research, and well-founded research.”
For example, one 2016 analysis by Joanna E. Bettmann, a professor at the University of Utah who studies treatment methods for troubled adolescents, found positive outcomes associated with wilderness therapy. Bettmann and colleagues found that wilderness therapy participants saw “medium-sized” effects on their self-esteem, personal effectiveness, interpersonal skills and behavioral outcomes.
Proponents of the practice say that being outdoors—as opposed to in a more traditional therapy setting—carries additional benefits for troubled teens.
“It really gets them down to basics and gets them out of their current environment,” Whitney Duhaime, vice president of the patient advocacy group Denials Management Inc., told Bloomberg BNA.
The industry has a growing number of supporters, but it also has a checkered past. A 2007 study by the Government Accountability Office details several instances of children dying while attending wilderness-type or boot camp programs. In some cases, program staff failed to properly respond to children who sustained injuries or experienced medical issues while hiking in challenging conditions, the report suggests.
Denials Management is a Utah-based company that negotiates with insurance companies on behalf of patients challenging denied claims. Its president, Mary Covington, said she took on wilderness therapy as her “baby” after the mental health parity law went into effect. Covington claims that Denials Management has recovered about $4 million on behalf of families that sought insurance coverage for wilderness therapy treatments.
In addition to these recoveries, Covington is celebrating another victory for wilderness therapy: The treatment recently received a revenue code that insurers can use when processing claims.
Todd Omundson, secretary for the National Uniform Billing Committee, confirmed to Bloomberg BNA that a revenue code for “Outdoor/Wilderness Behavioral Healthcare” will go into effect in July. Omundson said the new code was driven in part by a need to distinguish wilderness therapy from residential treatment facilities that serve similar populations.
Another factor pushing wilderness therapy toward mainstream acceptance? Licensing and accreditation.
Omundson said that at least five states now regulate wilderness therapy programs through licensing requirements: Utah, Colorado, North Carolina, Arizona and Maine. The licensing requirements in Utah—which is home to programs like Elements Wilderness, Second Nature and Aspiro Adventure—set qualification and training requirements for therapists and staff and establish health and safety standards for the participants.
Similarly, many programs are now accredited through the Outdoor Behavioral Healthcare Council. The council, founded in 1996, began a voluntary accreditation program for wilderness therapy programs in 2013. Twelve programs are currently accredited and five more expect to complete the accreditation process in the next few months, Jim Lavin, administrative manager for the council, told Bloomberg BNA.
According to the council, accreditation is an “impartial validation” that a particular program meets or exceeds standards developed exclusively for wilderness therapy programs.
Although the mental health parity law has been around for nearly a decade, few attorneys have shown interest in bringing cases under the law, Denials Management’s Covington said.
“We had trouble finding an attorney who was interested in taking a wilderness case, because they typically involve somewhere between $25,000 and $40,000,” Covington said. She contrasted this with lawsuits involving mental health treatments at residential facilities, which she said can involve more than $100,000.
That changed when she met Jordan Lewis, the Florida attorney who has filed at least five proposed class actions on behalf of wilderness therapy patients.
Lewis, who said he has seen personally how wilderness therapy can benefit troubled adolescents, said that the smaller number of potential plaintiffs in wilderness cases may make them less attractive to plaintiffs’ lawyers.
While other types of insurance coverage disputes may involve “hundreds and hundreds” of plaintiffs, wilderness therapy cases may involve only “dozens and dozens,” Lewis said.
“This isn’t a pro bono effort for me. I have to make this make economic sense for me and for my firm,” Lewis said. “But it doesn’t take hundreds and hundreds of people for the economics to work for me. There’s no giant payday at the end of this, but there’s enough to make this work.”
Although Lewis and his partners appear to be the only attorneys filing proposed class actions in this space, a Bloomberg BNA analysis shows that at least five other legal teams have filed individual wilderness therapy lawsuits in the past year.
Although wilderness therapy may not involve eye-catching sums of money from the perspective of a plaintiffs’ attorney, it remains an expensive proposition for individual families. Open Sky Wilderness Therapy, a Colorado-based facility accredited by the Outdoor Behavioral Healthcare Council, charges $565 per day, a price tag not out of line with the industry. Utah-based Legacy Outdoor Adventures boasts a $485-per-day price tag on top of a $2,700 enrollment fee. This puts a typical 10-week stay at nearly $40,000—an amount beyond the reach of many families without help from insurance.
Even so, proponents of wilderness therapy say it could be a cost-effective option in the long run.
The amount at stake in most insurance disputes over wilderness therapy is between $25,000 and $40,000, Denials Management’s Covington estimated. While that may sound like a lot, it’s significantly less than the $80,000 to $120,000 that a family could expect to spend on treatment at a residential facility, Covington said.
“It’s not a brick-and-mortar operation,” Denials Management vice president Whitney Duhaime told Bloomberg BNA. “They’re out in the wilderness, and they’re camping and cooking their own food.”
Gass, the professor who studies wilderness therapy and advocates its use, said that two ongoing research projects are examining the costs and benefits of wilderness therapy. The preliminary results of those projects, Gass said, suggests that enrolling in wilderness therapy programs could be a money-saving proposition in the long run, given the costs that could arise when a troubled adolescent doesn’t get help.
“We’re getting to the point of showing an insurance company that it’s actually less money if you place the child in these programs than if you don’t,” Gass said.
Bloomberg BNA reached out to several major health insurers and industry groups to get their thoughts on wilderness therapy as a covered expense under their plans. Many declined to comment.
America’s Health Insurance Plans, the industry group representing health insurers, said through a spokeswoman that the group had no “perspective” on wilderness therapy at this time. A spokeswoman for the ERISA Industry Committee, which advocates for large employers on retirement and health benefit issues, told Bloomberg BNA that it hasn’t discussed wilderness therapy with its members.
One insurer, Aetna, pointed to a clinical policy bulletin designating wilderness therapy as a treatment that the insurer considers “experimental and investigational” and thus generally not covered. According to Aetna, there is “inadequate evidence in the peer-reviewed published medical literature” demonstrating the effectiveness of wilderness therapy. Similarly, Oxford Health Insurance has suggested in court filings that it doesn’t consider wilderness programs to be “evidence-based treatment.”
Cigna, which declined Bloomberg BNA’s requests for comment, recently suggested in court documents that wilderness therapy isn’t categorically excluded as a covered expense; rather, claims for coverage of wilderness therapy are individually evaluated for medical necessity and other plan coverage provisions.
Insurers are sometimes willing to cover wilderness therapy, but questions of medical necessity and treatment parameters can complicate the inquiry, Jonathan M. Herman, a Dallas-based attorney who represents health insurance companies, told Bloomberg BNA.
The issue is especially complicated, Herman said, because the adolescents who participate in wilderness therapy often have multiple behavioral and mental health issues that haven’t been successfully treated through other programs, facilities or medications. A parent sending a child to wilderness therapy may be at wit’s end, Herman said.
“A parent wants no holds barred in the treatment of their child,” Herman said. “But from the insurance company’s standpoint, it’s bound by what the policy says. If a policy covers wilderness therapy, insurers look at whether that’s the best treatment for the child, notwithstanding the emotional undercurrent where the parent wants to do everything possible to treat that child.”
Herman said that insurers may be disinclined to cover wilderness therapy when they feel another covered service—like partial inpatient treatment—could meet the patient’s needs. Similarly, an insurer might cover a portion of a wilderness therapy program but deem an extended stay unnecessary and thus not covered, Herman said.
“My experience is that the insurance companies really do try to afford the benefits that are there,” Herman said. “There’s no real evil intent on the part of insurance companies to deny coverage for purposes of profit. At least I haven’t seen it.”
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