South Florida Under Attack
… and Uninformed People Think it’s Ok
Recently I received a link to an article written by a well-intentioned reporter for the Palm Beach Post on the State of the Treatment Industry in South Florida. Of course the writer had no idea of the truth, history of and how the Human Service industry has evolved. The writer utilized inflated numbers to point to how Treatment Providers in their “Bentleys” are fleecing patients and their insurance companies and making millions of dollars on unnecessary urinalysis and drug testing! The numbers made me want to go into the lab business…
Yet, I open the Explanation of Benefits on a daily basis and know the truth! And the truth is staggering! With over 30 years human service experience, currently as a treatment center operator, with extensive experience from the bottom up as a case manager, therapist, program director and not-for-profit executive; I have seen the cycles ebb and flow… Quite frankly, where there is smoke there is fire so simply dismissing the negative press and outrageous rumors circulating about indictments and the FBI at the ready to bring down the industry in South Florida, it would be foolish to minimize the concern by anyone with an interest in addiction treatment. And yes we all have an interest in addiction treatment; people are dying every day that are afflicted by addiction!
Treatment Provision History
During the late 80’s and early 90’s a Treatment Episode started moving to twenty eight-day “rehab” stints. Even though research indicated that 90 days of treatment produced the best results. Why did this shift occur? Additionally, “Inpatient” rehab became less and less available as institutional providers began to shift their focus away from alcoholism and addiction service. Why? Yet, every State in the Union recognizes the public health crisis of addiction. Each State has regulatory legislation on the books. Further complicating the process Government began their shift moving away from funding via grants and shifted the burden to a Managed Care service delivery system.
For the indigent and folks that met minimal financial criteria, beds for treatment were available, although limited. It is not a poverty issue, in fact the New York Times recently highlighted an ongoing epidemic among Lawyers. For middle income and above families and individuals that can self pay, those with the unicorn health insurance policy or for Union or corporate employees; EAP programs would pay for residential care. By the late 90’s Partial Hospitalization and Intensive Outpatient programs became the preferred choice for the insurers. This lowered their costs for treatment to an acceptable level while still providing access to care. States like Florida and California began to create a model of care based around those parameters. Many of the other States, New York for instance relied on a licensing system based upon need (Certificate of Need) that became impossible to secure due to several factors, thus the shift for the provision of service moved south and west! A win-win for everyone.
Well at least until the President GW Bush era when Patrick Kennedy was successful in adding the “Parity Provision” into the “Bailout” legislation. Followed by the Affordable Care Act, “Obamacare.” Couple that with the Opiate epidemic and rapidly, treatment providers began to spring up on a daily basis. Legislation in these states allowed for anyone, including someone with no experience recently discharged from treatment himself or herself, to apply and secure a license.
Bam, the perfect storm, Insurers do not want to pay, in fact the insurance industry attacked the laws and lost, coupled with greed and an influx of unskilled service providers, created the potential for fraudulent activity i.e. improper billing, standards of care lowered, evaluation process skewed to ensure the highest level of care, the legal definition of “disability” offering agencies and consumers the protection needed to allow for Day/Night service thus diminishing zoning requirements.
Add to that the ancillary service providers like Labs, pushing the envelope, sober living and halfway house providers trying to maximize their revenue working conjointly with unscrupulous IOP programs “paying rent” or marketing contracts and in some cases opening their own laboratory services as well, pushing the envelope and testing on nearly a daily basis. Something had to give! As is with anything there are always differing views or perspectives and the provision of treatment services is not excluded.
In August Cigna began their assault on South Florida “Out of Network” providers led by William Welch II. Welch the former Chief of the Public Integrity Section of the United States Department of Justice, reportedly forced to resign from the DOJ amid allegations his legal team purposely hid exculpatory evidence in a case against an Alaska Senator. As Associate Chief Counsel at Cigna Health Insurance, Welch single handedly has lead the assault on the industry standing on his corporate perch, vowing to bring profit back to the insurer. Pissed off that Behavioral Health is on par with medical health, insurers are fighting, kicking and screaming to avoid doing what they are paid to do, provide the necessary medical care to those that have chosen to spread the risk amongst themselves, “policy Holders”. Led by Welch, Florida treatment agencies were sent similar audit letters by the Cigna “Special Investigation Unit” (SIU) to audit several charts up to hundreds of charts per agency.
Sounds like a checks and balances approach by the insurer at face value, right? Well, five months later, most of Cigna’s claims for each agency have been frozen. Furthermore, not only has Cigna failed to pay the claims in a timely fashion, they are also taking the “Mafia” approach by attempting to force agencies to repay past claims in order to “negotiate” a settlement offer. All baseless propaganda and tactics by the insurers as they are hiding behind the veil of “Does Not Meet Medical Necessity” criteria, of course this is all part of their strategy from the start. What a great strategy, fight potential fraud with blatant fraud!
From the outside looking in this seems reasonable, but in reality, this is an out and out assault on the health care industry and quite frankly the lives of Americans afflicted with addiction. If we allow them to get away with this then what comes next? “U.S. corporate pencil pushers, medical professional failures and litigators that believe there is no medical necessity for your heart bypass surgery, because it doesn’t meet their (fiscal) medical necessity criteria?” Making matters worse, United Health and Healthnet are now following suit! Department of Justice do you hear that? Does the term “Collusion” mean anything to you? Politicians, do you hear that? Yes you are pushing the “Comprehensive Addiction and Recovery Act,” which will mostly benefit the indigent, but if you allow this to happen a huge vacuum will emerge once again in middle-income communities, you can expect an increase in overdose deaths in the suburbs.
Addiction Treatment providers are governed by Florida Statute, 65-D-30, the legislation requires treatment providers to abide by the “American Society of Addiction Medicine” (ASAM) criteria for admission to, continued stay and of course proper “step-down” for Level Of Care. Insurers have long held that this criteria is the basis for treatment at these levels of care, yet, a flunky, typically an RN that has been barred from direct care for substance abuse themselves, never meeting the client, via a simple phone conversation either approve or decline treatment and continued stay. The criteria they utilize? Dollars and Cents! Their jobs rely on it, their bonuses, and of course their salaries rely on it. Peer-to-Peer reviews are a joke, in fact typically the Medical Doctor for the insurer will inform the agencies Medical Professional before the review, I am not going to approve this level of care and insinuates that the lower level of care could be in jeopardy if they proceed! Please someone explain to me how is this legal? The Rico indictments need to start at the level of the Insurers Executive Teams and their legal teams, like Welch!
So what can be done?
“Do nothing” which most providers are doing exactly that, hoping they get through this in fear that they will be singled out by The Mafioso Insurance Industry. In theory providers could appeal to the Commissioner of Insurance. Complicating matters, this is the State of Florida and filing a complaint to the Commissioner coupled with a dollar fifty will get you on a bus. In States like New York the Commissioner actually does their job and responds to these clear violations of law. Remember, people, kids, moms, dads, brothers, sisters are dying every day! Politicians like Chris Christie (see Huffington Post) are speaking out and recognizing that addiction is killing our communities, America is faced with the worst opiate (and opioid) epidemic we have ever faced, coupled with alcoholism levels remaining steady at 6.8% of the population according to the National Institute on Alcohol Abuse and Alcoholism (NIH) and to top it off, the country does not have enough treatment beds to care for those in need as it is.
What treatment providers can do: