The Federal Opioid Fraud and Abuse Detection Unit: An Enforcement Initiative Lacking in Resources for Prevention and Treatment of Opioid Abuse

By: Jacqueline Bain

Earlier this month, Attorney General Jeff Sessions announced the formation of the Opioid Fraud and Abuse Detection Unit, which is a pilot program of the United Stated Department of Justice. AG Sessions noted that there are three components to approach the opioid crisis that our nation faces: prevention, treatment and enforcement.

  1. Prevention. AG Sessions noted briefly that the DOJ is undertaking that component through raising awareness, through drug take-back programs, and through DEA’s 360 Strategy program, which incorporates law enforcement, diversion control and community outreach to tackle the cycle of violence and addiction in US cities. He also stated that law enforcement is a component of prevention.
  2. Treatment. AG Sessions articulated that treatment can help break the cycle of addiction and crime and help people get their lives back together.
  3. Enforcement. AG Sessions dove deep in the area of enforcement, reasoning that enforcing our laws helps keep drugs out of the hands of our citizens, decreases their availability, drives up their price, and reduces their purity and addictiveness. He added, “Enforcement will make a difference in turning the tide in this epidemic.”

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Addiction Treatment Law Changes Management Relationships

healthcare regulatory complianceBy: Jeff Cohen

Passage of the new and comprehensive Florida addiction treatment industry legislation (CS/CS/HB 807) will send addiction treatment facility management relationships back to the drawing board.  Prior to the new law, some DCF licensed facilities were managed by management companies, some of which were owned by people who either did not qualify to be on the DCF license or who did not want to be visible on the license.

The new addiction treatment law requires all such arrangements to be reconsidered.  Here’s why:  There are several sections in the new law where management is the subject of intensive focus.   Newly created 397.410 requires DCF to establish minimum licensure requirements for each service component limited in part to the number and qualifications of all personnel, including management.  Newly created 397.415(1)(d)1 authorizes DCF to deny, suspend or revoke licensure of any license based on a “false representation of a material fact in the licensure application or omission of any material fact from the application.”  Finally, 397.415 creates an entire category of potentially punishing fines and, in some cases, exposure to criminal prosecution.

The new law will create heavy regulatory suspicion for any non-transparent management relationship, even a third party relationship.  Worse, it’s conceivable that any suspicious or arguably noncompliant relationship could form the basis for recoupment by insurers.  When the state Health Care Clinic Law was created some years ago, payers took advantage of situations where facilities that required a license but didn’t have one.  Under a threat of insurance fraud (e.g. an unlicensed healthcare facility receiving compensation for services), some payers were able to extract huge recoupments.

Any DCF licensed facility with a third party management relationship needs to reconsider it in light of the new addiction treatment law.  Moreover, all interested parties should pay close attention to (and monitor and participate in) the new law’s rulemaking process which began at the end of June.

CLICK HERE for: SUBSTANCE ABUSE MARKETING SERVICE PROVIDER LICENSE APPLICATION

Addiction Treatment Law Evolution: EMTALA Needs Updates for Opioid Crisis

By: Karina Gonzalez

With the opioid epidemic in South Florida at crisis levels, there is an increasing demand on local hospital emergency departments for screening and evaluations of drug overdoses, considered a medical emergency. Addiction treatment law evolves with EMTALA updates.   Many patients receiving substance abuse treatment in this community are coming from out-of-state.  Many are young, under 35 years and a majority receive outpatient services.  Overdoses are occurring more frequently as patients deliberately misuse opioid prescriptions such as Fentanyl or an illicit drugs such as heroin.  If the patient possesses and or uses an illicit drug while in treatment, the policy in many facilities is to terminate treatment and discharge the patient. But if the patient has overdosed, the facility will place a call to 911 and that patient will end up with a visit to a local emergency department.   A discharged patient will often continue using and end up in the emergency department, taken there by paramedics or some other individual.

Evolution of EMTALA

Local emergency departments now play a pivotal role in the next steps that an overdosed patient may take.   Is the patient receiving their EMTALA rights (Emergency Medical Treatment and Labor Act), a federal law requiring anyone coming to a hospital emergency department to be screened and examined?  If an emergency medical condition exists, treatment is provided to relieve or eliminate the emergency medical condition within the service capability of the hospital, a difficult task with substance abuse. Continue reading

Addiction Treatment Industry Becomes Familiar with Immunity

I suppose it is tempting, if the only tool you have is a hammer,

to treat everything as if it were a nail

–Abraham Maslow, “Toward a Psychology of Being”

By: Jeff Cohen & Randy Goldberg

The dominant forces of change in the addiction treatment industry are law enforcement and insurance companies.  The focus and impact of insurers is currently focused on the argument that what treatment providers do isn’t medically necessary.  This rationale is undeniably misguided  and is the biggest threat to the survival of many health care providers, including those at the forefront of adapting to the demands by implementing meaningful legal regulatory compliance.  This focus of this article is a parallel intervening factor in the addiction treatment industry:  that of law enforcement, most notably in Palm Beach County, Florida.  Consequently, providers in the addiction treatment space and their employees are becoming increasingly familiar with the concept of immunity as they are deal with law enforcement on a routine basis.

We assume there are bad-actors in the addiction treatment space.  There are bad-actors in every industry and profession.  No one can appreciate that more than this article’s co-author, Randy Goldberg.  He is a retired Florida law enforcement professional, who spent a significant portion of his career investigating law enforcement officers for alleged criminal misconduct, having been deeply involved in the arrest and successful prosecution of law enforcement officers who abused their authority and strayed to the dark-side of the law. Continue reading

Beware The Hypnosis of Crisis

By: Jeff Cohen

One of the biggest challenges faced by addiction treatment providers today, especially in Palm Beach County, Florida, arises in the context of unprecedented pressure by law enforcement via the Sober Home Task Force, newspapers and insurers.  The threat of being targeted by law enforcement is an enormous thing in itself.  Add to that the mainstream media’s insatiable desire for readers, the industry’s drop into insurer red flagging and recoupment, the political football nature of addiction and addiction treatment, and treatment providers can lapse into a state of paralyzed tunnel vision, a sort of mass hypnosis.  Here’s the problem:  providers dealing with the current compliance crisis environment have a lot to lose if they take their eye off the bigger picture.  The more absorbed they become in “crisis mode,” the more likely they will miss important addiction treatment compliance details in an increasingly regulated and changing industry.  Losing the ability to see the entire picture (and trends) and quickly adapting to it can have costly (and even deadly) consequences.

The addiction treatment industry is like any other healthcare provider—enormously and increasingly regulated, highly scrutinized and always dynamic.  The moment it took on features of traditional healthcare (e.g. lab and physician services), it left the relatively warm and fuzzy comfort of behavioral health providers, sorta.  “Sorta” because medical behavioral health (e.g. psychology and counseling) has not had it easy in the past 10 years, as it came under crushing price compression with managed care driven networks and other price cutting middlemen that have often been owned or controlled by insurance companies.  Addiction treatment providers in the pure behavioral health space were “saved” from all this till about three years ago because they were out of network and not the focus of insurer driven price cuts.  As payors (and their price cut incentivized middle men) looked for more ways to drive up profits, the competitive and disorganized addiction treatment sector became a natural (and unprepared) sector to hit.  And they hit it hard!  Clearly, the Perfect Storm.  Addiction treatment providers now have no option but to learn to swim hard and fast in the ever changing river of the healthcare business industry.Continue reading

Recovery Business Marketing 2.0

By: Jeff Cohen

Concepts that drive sober home relationships like Anti-Kickback Statute, Patient Brokering Act and Safe Harbor have become ingrained in the minds of nearly every addiction treatment provider’s thought process, especially in Florida with the development of the Sober Home Task Force.  Providers now seem to fully embrace ideas like–

  • There’s a federal law (the Anti-Kickback Statute, the “AKS”) that can bring criminal liability for marketing done incorrectly;
  • There’s a state law, the Florida Patient Brokering Act (“PBA”), that can do the same;
  • Complying with the federal safe harbors and the bona fide employee exception is important, even when there are no state or federal healthcare program dollars involved;
  • Paying anyone for marketing, not just on a commission based sales model, without fully appreciate the applicable laws is dangerous, costly and invites criminal inquiries and liability; and
  • Achieving compliance with applicable federal law should be part of any recovery business’ overall compliance plan.

Recovery providers must become familiar with not only the AKS and state restrictions like the PBA, but also the law’s permitted examples, so called “Safe Harbors,” which specify specifically permitted arrangements (42 CFR 1001.952).  The “personal services arrangement and management contract” Safe Harbor, for instance, has particular application in the area of marketing, as does the AKS exception for “bona fide employment arrangements,” which apply to “bona fide” W-2 employees (entailing direction, supervision and control), but not independent contractor relationships.Continue reading

Residential Substance Abuse Treatment & Life Safety Code

By: Valery Bond, RHIT

Did you know as a residential addiction substance abuse treatment provider, your facility must know what is, and what is not, above your ceiling tiles?  Does your facility have a “No Smoking” sign at the main entrance?  Do you know which way the doors are supposed to close?  Want to grow your business?  Plan on expanding?  You will need an ILSM (Interim Life Safety Measure) completed; and, the ILSM must include an infection control acknowledgment.

The Bottom Line About ILSM for Substance Abuse Treatment

In simplicity, buildings serving patients must comply with the NFPA 101 (2012 edition) Life Safety Code.  Has your substance abuse treatment organization identified a Safety Officer?  Has the Safety Officer identified Life Safety Code problems?  If your answer is “No” to these two basic questions, it may be time for your practice to implement a Life Safety program.

Known as “Minimum Fire Safety Standards for Residential Alcohol and Drug Abuse Treatment and Prevention Programs, mental Health Residential Treatment Facilities and Crisis Stabilization Units”, this rule chapter must be applied and adhered to in all 24 hour, 7 day per week healthcare facilities, just like a traditional hospital.Continue reading

Healthcare Business Operations: Non-Profit Regulations for the Rehab Industry

By: Shobha Lizaso

There has been a growing trend in the substance abuse rehabilitation industry to provide services through a non-profit, tax-exempt organization. Unfortunately, there is also a growing trend relating to IRS audits of non-profits. An audit by the IRS can yield many negative outcomes, including the revocation of a treatment center’s tax exempt status and fines imposed on the organization and/or its Directors when the non-profit fails to operate within the rules applicable to 501(c)3 non-profit organizations.

A non-profit may be able to fly under the IRS’s radar for a few years, but as the years pass, the chances that non-profit non-compliance will be caught by the IRS grows exponentially.  To protect your non-profit, please follow some of these basic rules:Continue reading

Opioid Crisis: Payor Strategies to Reduce the Harm of Opioids

By: Karina Gonzalez

CMS recently published a white paper entitled “Healthcare Payer Strategies to Reduce the Harms of Opioids.” The white paper was prepared by the Healthcare Fraud Prevention Partnership (“HFPP”), which is a voluntary public-private partnership between the federal government, state agencies, law enforcement, private health insurers, employer organizations and fraud units to reduce fraud, waste and abuse.  The white paper gives information and provides insight on the way payors view addiction treatment.

HFPP identified five actions that should be considered for implementation by all payors as quickly as possible.

  • Train providers on Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain;
  • Promote access to and usage of Medication Assisted Treatment (MAT);
  • Promote the availability of Naloxone;
  • Encourage use of cross-payor data to identify fraudulent, wasteful or abusive practices associated with opioids in order to target corrective actions; and
  • Identify and disseminate effective practices across the healthcare sector.

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