How to find a good drug rehab that is not committing fraud?
You may or may not have heard about a few drug rehabs across the country, particularly some Florida addiction treatment centers, sober living homes, and organizations that have been investigated for fraud in the last few years. There are two primary types of fraud allegations some addiction treatment facilities have been accused of over the last few years: Patient Brokering and excessive UA testing (urinalysis drug testing).
The fraud allegations against drug rehabs often brought on by private, for-profit insurance companies (e.g. Blue Cross/Blue Shield, HealthNet, etc.) need to be put into perspective.
There are over 10,000 drug rehabs across the nation, however the number of total “beds” within these facilities, if filled to 100% capacity, could only treat about 4% of the 23 Million people addicted to drugs and alcohol every year in the United States. That means more drug rehabs would need to be created in the unlikely circumstance that everyone suffering from substance abuse, or alcoholism, decided they wanted to get help at the same time and had health insurance, or their own money, to pay for treatment (Note: having the money or insurance to pay for treatment is another topic entirely). However, despite the overwhelming need for more drug treatment facilities in the United States, there are powerful people, organizations, and companies that do not want more treatment for people suffering from drug abuse, primarily because it affects their own pocket-books.
Think about these facts –
• Fraudulent activity within the drug rehab industry only account for about .0006% of treatment facilities in the United States.
• Seldom do the accusations lead to actual convictions or arrests.
• The bulk of the few fraudulent accusations and news reports are over money, not poor patient care or treatment.
• The majority of treatment facilities in America are compassionate and caring; they provide treatment that often goes above and beyond state licensing standards.
Drug Rehabs and the Law Regarding Fraud in California:
The California Insurance Codes, the California Health and Safety Code, and the “Stark Law” are rules for drug rehab marketing and insurance fraud. Based on those laws, the following is a summary of what can and can’t be done.
Self-Referral Law – Stark Law
• It’s OK to pay a fair market price for the time skill and efforts involved in marketing a drug rehab for the purpose of obtaining clients
• Paying a marketer per referral is not an acceptable practice and could be construed patient brokering
Contracted Marketers (i.e., non-employees) –
• It’s not OK to pay an independent contractor or outside marketing company based on productivity bonuses;
• It is OK to pay that outside company a flat rate that doesn’t change for a year.
• If the person is an employee, it’s OK.
Outside Call Centers Paid Per Referral for Patients –
• It’s OK to have your own, company-owned and operated call center.
• It is not OK to pay an outside call center on a per patient referral basis.
• Paying for the volume of call center or marketing services utilized at a commercially reasonable price is OK. For example, 10 referrals a month or 20 a month, but not per patient.
Bed Vouchers –
• Quid Pro Quo arrangements with sober living homes using “bed vouchers” in exchange for referrals is a problem.
• Written contract to “rent” beds on commercially reasonable terms not affected by referral value or volume is permissible.
Procuring Insurance –
• Insurers have been investigating “gaming” behavior with exchange-based insurance plans.
• CMS has started investigating practice of “steering” consumers into exchange-based plans.
• Some people and companies have been paying for patient’s insurance plans but insurance companies (Remember, insurance companies are worried about bottom lines, not the lives of patients. Each patient that has benefited from someone else helping them pay for insurance to get treatment have gotten the treatment they desperately needed) are alleging to be a form of kickbacks because it induces patients to choose a specific treatment program that paid for their insurance.
Drug Testing in Drug Rehabs –
• Insurance companies do not like that drug rehabs are sending two urine tests per week, per patient to be analyzed by laboratories. Even though two urine tests a week sent to a lab for analysis has been shown to be a medically necessary standard that is needed to ensure that patients are not using any drugs or drinking alcohol while in treatment, the insurance companies have lost lots of money on the practice and have started to limit the amount of drug tests they will pay for per year.
• Drug testing more than is needed, that is, more than two times every seven days, has been an area where drug rehabs have taken advantage of the insurance payouts, however many drug rehabs across the nation, scared by insurance companies and negative news stories about over-drug testing have stopped billing insurance companies at all for the drug testing they conduct, and some do not even send the urine to labs for high complexity analysis, which is horrible for patient care and could result in more in-treatment deaths from overdose.
IMPORTANT NOTE – SAMHSA’s criteria for UA’s do NOT match with most insurance company’s standards for Urine Analysis testing frequency, so there’s definitely a large grey area and we in the industry should continue to fight for SAMHSA’s criteria as opposed to insurance company’s criteria for our patients.
Avoiding False, Misleading or Deceptive Claims – “Addiction Cure”
• A drug rehab cannot make false claims that they have the “addiction cure.” Such statements made by a drug rehabs must be supported by scientific research data.
• A drug rehab can’t “Guarantee Success.”