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.
Sophisticated addiction treatment providers are beginning to learn the hard way what every other healthcare provider has known for decades—details, details, details. It may be initially be shocking to need to have a nearly encyclopedic awareness of things like the OSHA Bloodborne Pathogen Standards, CPT 9 and 10, the difference between behavioral health and medically driven medical necessity documentation requirements, HIPAA Business Associate responsibility and liability, well established fraud and abuse guidance, HITECH Act driven EMR issues and such, but traditional healthcare providers have been steeped in such things since the 80s! Hence the shock to the collective addiction treatment system as these providers came “on line” into the most regulated environment imaginable. In fairness, traditional healthcare providers have had professional organizations (e.g. the American Medical Association, the American Hospital Association) at the table creating these regulations and then taking the lead in disseminating them to their provider members. CME for professional organizations is partly driven by the need for legal butt covering as regulations grew like algae. Survival in the healthcare business industry has always depended on the ability to assess the entire landscape and to adapt quickly. In deciding not to lead their industry into its future, addiction treatment providers are at a serious disadvantage and need to play catch up.
It’s impossible now for addiction treatment providers to ignore the regulatory details. Issues like fraud and abuse and medical documentation requirements have become part of every day speech. The brewing problem that isn’t yet talked about is the fact that, in responding only to the issues that are front and center with law enforcement, newspapers and insurers, addiction treatment providers are likely missing other serious and important details. Are they organized properly? Are they self-auditing at least once a year on issues of proper medical record keeping? What about coding and reimbursement auditing—matching CPT-driven criteria to the HCFA claim form? Are they fully aware of pertinent CLIA regulations and Joint Commission requirements? Are they anticipating the expansion of such regulations as accrediting bodies find new ways to create a market in addiction treatment? It wasn’t long ago that Joint Commission accreditation was just for hospitals, skilled nursing and home health. They saw an untapped market in addiction treatment and went for it! Organizations like the Joint Commission can be expected to continue their Sherman’s march across the industry as they attempt to open new revenue sources within healthcare. And who can blame them? There is a big and growing need.
The more “medicalized” the addiction treatment space becomes, the greater the need to “slot into” well-worn compliance requirements that exceed today’s crisis points. The good news is that these issues are nothing new. Hospitals and physicians in particular have navigated them for decades, and to great effect. Addiction treatment providers that are able shake the spell of the current industry hypnosis will accept their new status within healthcare, will take a step back, embrace the need for far greater and expansive self-regulation and even lead it! Those who thrive will have developed a far more expansive understanding of the healthcare regulatory landscape and will become experts in the healthcare business sector.