Tag Archives: insurance

Negative Press Causing Referrals to Florida to Come Into Question

The Portland Press Herald reported on July 19, 2017 in the article “Operation Hope stops sending clients out of New England for opioid addiction treatment” about how the Scarborough (Maine) Police Department’s Operation Hope has stopped sending clients out of New England for treatment for opioid addiction, largely because of negative media about alleged unscrupulous programs, especially in Florida (a story published in May by STAT, a health journalism website that partners with The Boston Globe, detailed alleged insurance scams and referrals to Florida clinics where patients were receiving little or no treatment).

Launched in 2015, Operation Hope was conceived as a way for police to channel addicts who sought help into a treatment program as an alternative to criminal prosecution on drug-related charges.

In most cases, getting help from Operation Hope meant flying out of state – to Florida or one of eight other states – because Maine lacked treatment opportunities. In the program’s first six months, four out of five Operation Hope participants headed out of Maine, mostly to clinics in Florida, Arizona and Massachusetts.

“We always wanted to help people closer to home, but we really had no other choice. That was the only way to get people help,” said Steve Cotreau, program manager at Portland Community Recovery Center. The nonprofit social support center for people in recovery has helped with Operation Hope placements.

With the current black-and-white approach that many law enforcement agencies are taking with regard to “regulation” of treatment providers, many good providers are electing to close up shop due to lack of regulatory guidance. When the only guidance available is a knock at the door from a detective claiming you have violated the law, when the lawyers themselves may disagree whether the law was violated, but it is to be “left up to the judge and jury” to determine one’s fate, many good providers are simply walking away.

There is an absolute vacuum of publicly-funded beds in Florida, and nationally. Even when there is some modicum of availability, these facilities are generally not accessible to persons who do not qualify as being impoverished, and are often staffed by persons who lack the experience or education to be administering what is becoming an overwhelmingly medical modality.

The ignorance from the regulatory bodies about how the private sector must be allowed to work is impeding innovation as well as necessary investment in technologies for growth. A truly progressive society would stop complaining and fully support the treatment industry altogether.

The apparent restriction of prosecutorial discretion for purposes of achieving popular political gains is not only short-sighted, but also has a significant negative impact upon the substantial legitimate employment that the industry provides, along with choking off the ancillary revenue that local businesses experience from developing recovery communities.

We will simply go from one crisis, to another.

Affordable Care Act Means More Young People Getting Needed Behavioral Health Treatment (Time Magazine)

A provision in the health care reform law allowing parents to keep their adult children on their health-insurance plans has led to millions more young people with mental-health and substance-abuse problems getting treatment, according to a new study.

http://time.com/3080227/obamacare-mental-health-treatment/

“The Affordable Care Act (ACA) required that insurers allow people ages 19–25 to remain as dependents on their parents’ health insurance beginning in 2010. Using data from the 2008–12 National Survey of Drug Use and Health, we examined the impact of the ACA dependent coverage provision on people ages 18–25 with possible mental health or substance use disorders. We found that after implementation of the ACA provision, among people ages 18–25 with possible mental health disorders, mental health treatment increased by 5.3 percentage points relative to a comparison group of similar people ages 26–35. Smaller, but consistent, effects were found among all young adults, not only those with possible illnesses. For people using mental health treatment, uninsured visits declined by 12.4 percentage points, and visits paid by private insurance increased by 12.9 percentage points. We observed no changes in mental health treatment setting. Outcomes related to substance abuse treatment did not change during the study period. The dependent coverage provision can contribute to a broader strategy for improving behavioral health treatment for young adults.”

How to Reconcile Integration with Anti-Kickback Laws and Market-Based Compensation

“Many hospitals are hiring and contracting with doctors to boost referrals and serve members in their coordinated-care networks. But how to pay those doctors has become a legally perilous area under the federal Stark and anti-kickback laws and the False Claims Act, with whistle-blowers, their attorneys and the Justice Department watching these transactions closely. Halifax and other recent big-dollar whistle-blower cases involving allegations that hospitals violated Stark self-referral rules in paying physicians highlight the huge stakes for hospitals, which are at risk for triple damages under the False Claims Act. Those damages are based on total billings, making the potential damages in these cases enormous.”

“The tough part for hospital leaders is that these legal pressures are at odds with public policy and market forces pushing health systems toward greater integration to improve care coordination and reduce costs. The federal government hasn’t reconciled its goal of encouraging integration with its desire to prove that it’s tough on fraud and abuse. As a result, systems pursuing integration will need to be even more vigilant because they’re stepping closer to the line where traditional Stark law enforcement might come into play.”

Read the full story here:
http://www.modernhealthcare.com/article/20140308/MAGAZINE/303089982/caught-between-competing-pressures?AllowView=VXQ0UnpwZTVDZlNXL1I3TkErT1lBajNja0U4VUNlWlZFQk1JQmc9PQ==&utm_campaign=am

Zoning – Cities Can’t Discriminate Against Providers

Once again (and again, and again), the NIMBY (Not In My Backyard) and the CAVEmen (Citizens Against Virtually Everything) pitchforks came out in mass to protest a methadone clinic opening in Philadelphia, notwithstanding that methadone clinics are otherwise allowed.

“The court also used a Third Circuit finding to bolster its conclusion, citing a 2007 ruling that found that municipalities are not free to hold methadone clinics to different zoning standards than ordinary medical clinics.”

There is no basis to treat medical and health clinics any differently from substance abuse clinics, but for the type of person to be treated.

I often find it comical (not really) when I bring to NIMBY’s attention that a MOD (medical office building) permits psychiatrists who have the right to see would-be mass murderers and potential child molesters, but heaven forbid people seeking recovery and solace from the scourge of drug abuse seek similar (if not less intense) medical and behavioral care, and the pitchforks and torches come off the shelves.

Check out this LAW360 article:
Pa. Court Says Philly Zoning Can’t Preclude Meth Clinics

Prompt Pay Laws

Many have been calling in recent days regarding insurance carriers refusing to pay for claims for treatment, essentially saying “sue us for your money.” Aside from potentially discriminatory undertones, this is patently illegal.

The State of Florida has what are known as “Prompt Pay” laws which require an insurance carrier to do just that. While I won¹t get into the details here, I thought I would share this article with you to illustrate that ³you are not alone² when it comes to this headache.

Read more about them with Law360’s article:
Hospitals Can Sue Under Prompt Pay Law: NY Appeals Court