substance abuse treatment fraud, abuses and other barriers to › wp-content › uploads › 2018...
TRANSCRIPT
1
Substance Abuse
Treatment Fraud,
Abuses and Other
Barriers to
Effective Care
Judi Braswell, LPC, CEAP, GBAVice President, Business Development
205.441.6866
2
About the Webinar
• Lines Are Muted
• Use Arrow To Minimize Menu
• View Slides in Full Screen Mode
• Enter Questions for Q&A Session
3
HRCI & SHRM Pre-Approved
In order to receive the HRCI* & SHRM** Credits:
• Must have signed in with your unique registration link
• Must attend the entirety of the webinar
• Must answer the applicable polls for HRCI credits
• An HRCI certificate with ID# will be sent to you upon completion of all of the above
• Make sure to add apbenefitadvisors.com to your whitelist/safe senders list to receive all follow-up emails
*The use of this seal confirms that this activity has met HR Certification Institute’s® (HRCI®) criteria forrecertification credit pre-approval.
**AP Benefit Advisors, LLC is recognized by SHRM to offer Professional Development Credits (PDCs) for SHRM-CPor SHRM-SCP. This program is valid for 1 PDC for the SHRM-CP or SHRM-SCP. For more information aboutcertification or recertification, please visit shrmcertification.org.
4
Magnitude of the Problem
Opiate overdose
deaths rose
400%since 2000
2.1 mil people
addicted to opiates
# 1U.S. Health Epidemic
50%of opiate
deaths involve Rx
$72.5 billion spent annually on treatment
2nd highest killer of young people today!
The definition of 'addiction': A chronic disease of the brain
5
Stricter restrictions of pain medication prescriptions
could solve the opioid epidemic.
a. True
b. False
6
The “Perfect Storm”
About three-quarters of the rehab center patients with private insurance come to Florida
from out of state, according to law enforcement officials in Palm Beach County. The
Affordable Care Act, which both mandates payment for drug treatment and makes private
insurance easier to obtain for young people, has created a pot of money that’s being
exploited by unscrupulous treatment centers, according to those officials.
ACA / Mental Health Parity changed the landscape for risk to insurers and revenue for facilities
Opioid epidemic surging
7
A Phone Call & An Airplane
Direct to consumer marketing
8
Key Elements in Effective Treatment
9
Treatment Modalities
Detox
Inpatient
Residential
Partial
Intensive outpatient
Sober homes/half-way houses
Aftercare
10
Effective Treatment
Patients enter at stage deemed medically necessary
Program length determined on case specific basis
Better outcomes when program close to home/strong support system
Allows for minimal disruption to work/home life
Provides long term recovery support system
Aftercare essential to long term abstinence
11
Most individuals abusing drugs require a minimum of
28 days inpatient in order to be sober for life.
a. True
b. False
12
13
…currently finishing up graduate school at Liberty University obtaining a Master of Arts in Professional Counseling and will be graduating in the Fall of 2017.
14
Fraud, Abuses & Other Barriers
Low value care
Deceptive practices
Criminal activity
15
Low Value Care
Lack of clinical assessment
Staff qualifications
Treatment hours
“Cookie cutter” approach
Little/no transition planning
No care beyond residential/inpatient
16
Deceptive Practices
Patient Brokering
Kick backs
Labs: high cost/frequency/types
Billing drug test by substance rather than panel
Ordering additional test (genetic, allergy, etc)
Bundled living arrangements
17
Criminal
Payment for referrals/tests
Allowing/encouraging drug use
Sex trafficking/prostitution
Withholding personal items for clients leaving early
Forging MDs signature
Unqualified staff dispensing detox drugs/dispensing without prescription
18
Individuals that are paid for admissions into
treatment programs are called:
a. Patient Advocates
b. Patient Brokers
c. Referral Agents
19
Grand Jury Makes Recommendations on
Abuses in Drug Treatment IndustrySouth Florida's drug treatment industry is plagued by "deceptive
marketing, insurance fraud and patient brokering.“
Sober Homes
Unregulated
Crimes like rape, theft, human trafficking, prostitution and illegal drug use are commonplace
Provider billed a single patient's insurance $600,000, mainly for drug tests, over a 7 month span
The 24-year-old Ohio native had come to Florida for treatment but died of an overdose.
Recommended requiring marketers and employees who admit patients for treatment be licensed
Sun Sentinel, December 12, 2016
20
Claims Analysis Insights
21
Claims Insights In the News
Jan – June 2016
$600,000
7 facilities
15 months
1.2 million
9 facilities
3 were later raided and shut down
One owner pled guilty to health care fraud, sex trafficking and prostituting clients
Wife was the named owner due to his previous felony conviction
She pled guilty to two felony counts
Included charges for daily counseling
and drug test that did not occur
22
Staff that determine appropriateness for inpatient
admissions to substance abuse treatment
facilities must be licensed within that state.
a. True
b. False
23
BHS Claims Insights
Spouse – 18 months, 9 treatment episodes, 7 different facilities
23 day opioid admit @ $68,429
$2148
No claims for lower levels of care
Opioid claims @ 30% of total MHSA
41% specific to labs (12% of total MHSA)
Anesthesiologist prescribed 1,970 doses of Methadone and 850 doses of Xanax over 8 months
“Proprietary” treatment only available at one group in one state for autism, adh, AND ATHLETES
24
Employer Strategies
25
Plan Design
Copay @ PCP
MH v SA cost sharing
Day & Dollar Limits
Residential care/SNS
MAT
Require accreditation of substance abuse treatment facilities
26
Substance abuse office visit copays should be
at the specialist level rather than PCP.
a. True
b. False
27
Employer Strategies
Provide an effective EAP with robust communications and
integration with medical case management
Strict monitoring of Rx claims data for doctor shopping / ER
visits / benzo and opioid combination scripts / medication
compliance
Enforce medical necessity criteria
Provide assistance with discharge planning/transition of
care for all mental health and substance abuse
Consider a MBHO
28
Judi Braswell, LPC, CEAP, GBA
Vice President, Business Development
Behavioral Health Systems
O: 205.879.1150
M: 205.441.6866
Questions?