9/7/2017 AMERICAN GREED: SUBSTANCE ABUSE & LIQUID GOLD SUBSTANCE ABUSE & URINE TOXICOLOGY BACKGROUND SUBSTANCE ABUSE & URINE TOXICOLOGY BACKGROUND

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1 AMERICAN GREED: SUBSTANCE ABUSE & LIQUID GOLD Presented by Karen Schwabacher of Schwabacher Health Insurance Consulting, Inc. 1 TOXICOLOGY BACKGROUND Many Different Levels of Treatment Options Outpatient Group Inpatient Partial/Day Hospitalization Residential 2 TOXICOLOGY BACKGROUND Types of Treatment & Places Subject to Eligibility/Coverage Interpretation By Pre-Certification Vendor Case Manager State Licensing Requirements General Definition Provider/Facility Definition 3 1

2 TOXICOLOGY BACKGROUND Types of Treatment & Places Subject to Eligibility/Coverage Interpretation By Coding Reference CPT HCPCS Revenue Codes 4 TOXICOLOGY BACKGROUND Types of Treatment & Places Subject to Eligibility/Coverage Interpretation By Policy/Plan Language Definitions Covered Expense Requirements Exclusions & Limitations 5 TOXICOLOGY BACKGROUND Types of Treatment & Places Subject to Eligibility/Coverage Interpretation By Automated Electronic Payment Medical Director/Reviewer Prior Handling Claims Payer Excess Loss Carrier Complicated & Challenging Reviews. Claims Paying Organizations Must be Diligent & be able to Support Eligibility/Coverage Determination. If Not, the Stop Loss Carrier May! 6 2

3 TOXICOLOGY DEFINING TERMS Substance Abuse Care Terms & Definitions Detoxification Performed on Either a Residential or Inpatient Basis & Generally Lasts Between 3 7 Days. Intensive Outpatient Program (IOP) Treatment Program That Offers Group & Individual Services From 3 5 Days Per Week. 7 TOXICOLOGY DEFINING TERMS Substance Abuse Care Terms & Definitions Partial Hospitalization Program (PHP) Patients Attend a Rehabilitation Center Every Day, But They Still Can Reside in Their Own Homes. AKA, Day Treatment. Sober Homes Housing Used by People Recovering from Substance Abuse, Which is a Stepping Stone Between Rehabilitation & Living Independently. AAA Halfway House 8 TOXICOLOGY DEFINING TERMS Substance Abuse Care Terms & Definitions Patient Brokers/Cappers Individuals Who are Paid Commissions (Kickbacks) for Patient Referrals. 9 3

4 TOXICOLOGY DEFINING TERMS Psychotherapy Terms & Definitions Family Focuses on Family Dynamics Group Not a Set Time or Set Number of People Individual Focus on One Person With or Without Others Present 10 TOXICOLOGY DEFINING TERMS Urine Toxicology Screening Terms & Definitions Point of Care Testing (POCT) Urinalysis Diagnostic Testing at or Near Where Patient Care is Being Rendered. Offers Immediate Results That are Less Sensitive & Less Specific Than IA Performed in Laboratory Setting. Qualitative Urine Toxicology Detects the Presence of a Drug or Drugs in the Body. NOTE: Can be Performed Either as a POCT or in a Laboratory. 11 TOXICOLOGY DEFINING TERMS Urine Toxicology Screening Terms & Definitions Quantitative Analysis A Test That Tells You How Much of the Drug or Drugs is Present in the Body. Quantitative/Confirmatory Testing: Offers the Most Sensitive & Specific Results Should be Performed in a Laboratory by Trained Professionals Under Quality Controls Equipment Requires CLIA Certification Cost Impacted by the Number of Drugs Being Tested for More Expensive Than Qualitative Longer Turnaround Time/Results 12 4

5 TOXICOLOGY DEFINING TERMS Urine Toxicology Screening Terms & Definitions Standing Orders Instruction for Ongoing Order or Procedure That Continues to be Followed Until it is Cancelled or Changed. Validity Testing Describes Tests Which Help Ensure that the Urine Sample has not been Adulterated or Substituted. 13 TOXICOLOGY DEFINING TERMS Urine Toxicology Screening Terms & Definitions Clinical Laboratory Improvement Amendments (CLIA) Centers for Medicare & Medicaid Services (CMS) Regulates All Laboratory Testing (Except Research) Performed on Humans in the US Through CLIA. CLIA Affects ALL Laboratories & Applies to All Plans, Whether Federal or Not. 14 TOXICOLOGY CODES Active HCPCS Codes to be Familiar With Include Behavioral Health HCPCS Codes H0015 Global Day Fee IOP (Treatment Program Operates at Least 3 Hours/Day & at Least 3 Days/Week & Includes Assessment Counseling Crisis Intervention Activity Therapies or Education 15 5

6 TOXICOLOGY CODES Codes to be Familiar With Include Behavior Health HCPCS Codes H0017 Hospital Residential Treatment Program, per Diem H0018 Non-Hospital Short-Term (30 Days or Less) Residential Treatment Program, per Diem H0019 Non-Medical, Non-Acute Care in a Residential Treatment Program Where Stay is Typically Longer Than 30 days, per Diem 16 TOXICOLOGY CLIA CERTIFICATION CLIA Certificates Include Waiver Allows a Laboratory to Perform Only Tests Categorized as Waived. Provider Performed Microscopy (PPM) Allows a Laboratory to Perform Tests Categorized as PPM and/or Waived Tests. 17 TOXICOLOGY CLIA CERTIFICATION CLIA Certificates Include Compliance Allows a Laboratory to Perform Tests Categorized as Waived, PPM, and/or Moderate to High Complexity. Accreditation Allows a Laboratory to Perform Tests Categorized as Waived, PPM, and/or Moderate to High Complexity. 18 6

7 TYPES OF DRUG TESTING Analytical Testing Performed for Detecting Drugs in Urine Screening Tests Confirmatory Tests 19 TOXICOLOGY SCREENINGS Reasons for Drug Screening/Testing Suspicion of Drug Abuse or Diversion State Mandates Concerns Regarding Therapeutic Compliance Monitoring During Drug Abuse Rehabilitation 20 TOXICOLOGY SCREENINGS Increased Utilization Occurring Due to Rapidly Changing Technology & Testing Options Expanding POCT Choices Office Desktop/Benchtop Analyzers High Profitability Controlling Inappropriate Medication Utilization 21 7

8 TOXICOLOGY SCREENINGS Increased Utilization Occurring Due to Increased State Board Mandates Escalation of Providers Financial Interest Minimal Regulation Around Appropriate Testing Fear of Litigation If Testing Not Performed Concern Regarding Malpractice 22 SCREENINGS: FINANCIAL INCENTIVE Toxicology Laboratories May Partner With Substance Abuse Treatment Facilities Substance Abuse Providers NOTE: The Above May Include: Sober Housing Halfway Houses 23 SCREENINGS: FINANCIAL INCENTIVE Toxicology Laboratories May Partner With Pain Management Facilities Pain Management Providers 24 8

9 SCREENINGS: FINANCIAL INCENTIVE What a Limited Partnership May Look Like Facility/Provider Invests in Toxicology Laboratory & Purchases a Share for $12,000 Facility/Provider Agrees to Send a Minimum Number of Specimens a Month Facility/Provider s Investment Will Yield About $3,500 a Month 25 SCREENINGS: FINANCIAL INCENTIVE Toxicology Laboratory May Provide POCT Supplies to Facility/Provider at No Cost in Exchange for Facility/Provider Sending Samples to Laboratory for Further Screening Be Out-of-Network 26 SCREENINGS: FINANCIAL INCENTIVE The Reality Check! Encourages More Frequent Testing & Panels Costs Vary for Both POCT & Confirmatory Testing, But Generally Ranges Between $1,200 - $2,500 per Specimen for POCT $750 - $2,500 per Specimen, but are Dependent Upon the Number of Screenings Performed Do the Math Multiply This by 2 5 Times a Week by the Number of Weeks Per Patient!! 27 9

10 SCREENINGS: FINANCIAL INCENTIVE Guess What? Larger Treatment Facilities/Centers are Building Their Own Laboratories Minimal Regulations I call this LIQUID GOLD! Toxicology Laboratories Do Not Accept Medicare Or Medicaid Ask Yourself Why? 28 COMPLIANCE/MEDICAL NECESSITY Basic Compliance Issues for Urine Toxicology Testing by Laboratories Confirmatory Testing of Negative POCT Results Requires the Healthcare Provider to Document Clinical Reasons to Believe the Negative Result was Inaccurate or Inconclusive Clinical Laboratories Must Have a Compliance Program to Detect & Prevent Healthcare Providers from Performing Unnecessary POCT & Ordering Unnecessary Confirmatory Testing 29 COMPLIANCE/MEDICAL NECESSITY Basic Compliance Issues for Urine Toxicology Testing for Laboratories Clinical Laboratory May Not Offer Below Market Value POCT Tests and Consulting Agreements to Induce Healthcare Providers to Refer Tests Laboratories May Not Waive Patient Financial Responsibility to Induce Healthcare Providers to Refer Urine Specimens 30 10

11 COMPLIANCE/MEDICAL NECESSITY Urine Quantitative/Confirmatory Test Requisition Orders Should Document Name of Patient Date/Time of Specimen Collection Name of Ordering Practitioner List of Medications 31 COMPLIANCE/MEDICAL NECESSITY Urine Quantitative/Confirmatory Test Requisition Orders Should Document (Cont d) Indication of Drug(s) to be Tested Signature (or Stamp) of Physician Signature of Patient Proceed with Caution if This Information is Missing! 32 COMPLIANCE/MEDICAL NECESSITY Summarization of Article by the American Society of Addiction Medicine (ASAM) Perform Medically Necessary & Accurate Testing for the Drugs That are Most Likely to Impact Medical Decisions Based on Clinical Situation Patient Risk 33 11

12 COMPLIANCE/MEDICAL NECESSITY Summarization of Article by the American Society of Addiction Medicine (ASAM) (Cont d) Cost Must be Considered in the Choice of Drug Testing & Requires Clarification Regarding the Purpose of Testing Selection of Testing Strategy Matching Purpose Ensuring the Cost of Testing is in Alignment With the Expected Benefit(s) 34 COMPLIANCE/MEDICAL NECESSITY Summarization of Article by the American Society of Addiction Medicine (ASAM) (Cont d) Testing Should be Individualized for Each Patient and Not Determined by a Forced Panel of Drugs Individuals Being Tested Should Be Informed of the Reasons for Testing Know the Consequences to an Unexpected Positive Result (Preferably in Writing) Before Testing 35 COMPLIANCE/MEDICAL NECESSITY Summarization of Article by the American Society of Addiction Medicine (ASAM) (Cont d) Frequency of Testing for Individuals With Substance Use Disorders in Addiction Treatment Programs Should be Tested Randomly With Unpredictable Testing More Frequent Testing at the Beginning of Treatment After Substantial Period of Proven Abstinence, Testing Less Frequently 36 12

13 COMPLIANCE/MEDICAL NECESSITY Summarization of Article by the American Society of Addiction Medicine (ASAM) (Cont d) There is no Agreed Upon Standard. In General, Most PHPs Set the Frequency of Random Testing at Once a Week Early in Their Monitoring. The Frequency of Testing is Reduced to Twice a Month and Then Once a Month After Long-Term Sobriety is Achieved. 37 COMPLIANCE/MEDICAL NECESSITY Summarization of Article by the American Society of Addiction Medicine (ASAM) (Cont d) POCT Provides Rapid Results, but are Limited in Terms to Specificity & Accuracy in Comparison to Mass-Spectrometry Methods Determine the Questions the Tests are to Answer With a Plan for What to do with the Results No Compelling Rationale for Subjecting All Negative IA results to Definitive Testing It s All About That mass! 38 COMPLIANCE/MEDICAL NECESSITY Summarization of Article by the American Society of Addiction Medicine (ASAM) (Cont d) Qualitative Testing of Positive Results (and at Times Negative Results) Guidelines POCT Without Definitive Testing to Confirm Positive Results is Often Sufficient Unexpected Positive Results &/Or Unexpected Negative Results Questions the Tests are to Answer Should be Determined Prior to Administration With a Plan for What to do with the Results Prompt Further Investigation 39 13

14 COMPLIANCE/MEDICAL NECESSITY Summarization of Article by the American Society of Addiction Medicine (ASAM) (Cont d) If Unexpected Absence of a Prescribed Drug on an IA Test is at Odds With the Patient s Account of Medication Use, Definitive Testing of the Specimen is Strongly Suggested. There is No Universal Standard in Either Medication Monitoring or for Drug Testing in Addiction Treatment Cost Must be Considered in the Choice of Drug Testing in Balance with the Clinical Goals for Each Patient 40 TOXICOLOGY Frequency of Testing Issues & Questions to Ask: Did the Test Requisition Order Include the Elements? NOTE: Pay Particular Attention to the List of Medications. Is the Ordering Physician Documented in the Records as Seeing the Patient? Were the Results Returned & Reviewed Prior to Ordering Additional Tests? If There was an Unexpected Positive Result, Were There Documented Repercussions? And, if so, Were They Consistent the Program s Protocol? 41 TOXICOLOGY Frequency of Testing Issues & Questions to Ask: Is the Ordered Panel Consistent & Specific to the Patient s History? Was the Testing Performed on Consecutive Days? Was the Testing Performed Fairly Consistently on the Same Days of the Week? NOTE: This Would Suggest the Testing Was Not Random

15 TOXICOLOGY POLICY/PLAN Clear, Defined, Non-Conflicting, Unambiguous Policy/Plan Language is Imperative, Making Certain Group s Intention is Able to be Enforced It is in Compliance With Applicable Laws 43 TOXICOLOGY POLICY/PLAN Carefully Review the Policy/Plan for Applicable Schedule of Benefits Covered Expenses 44 TOXICOLOGY POLICY/PLAN Carefully Review the Policy/Plan for Applicable Definitions Covered Expense Covered Providers 45 15

16 TOXICOLOGY POLICY/PLAN Carefully Review the Policy/Plan for Applicable Exclusions & General Limitations 46 Upcoding 47 Unbundling 48 16

17 Duplicate Billing 49 Not Medically Necessary 50 Billing Outside the Scope of License/Certification 51 17

18 Billing for Services Without Patient 52 Billing for Non-Covered Services NOTE: Require Documentation, as Defined by SPD 53 Unlicensed or Non-Covered Provider of Service 54 18

19 Always Out-of-Network 55 Treatment Facilities May Pay (Kickback) for Referrals NOTE: With Mandatory Up to 26 Year Old Coverage, This Practice Has Become More Prevalent. 56 Lists Unauthorized, Non-Contracted Payers Names on Web-Sites Which Leads Patients to Believe the Treatment Center is a Contract Provider/Preferred Provider 57 19

20 Frequent Urine Drug Screenings High Dollar Amounts Outside Laboratory and/or Out-of-Network Billing Multiple Test Components Billing for Qualitative After Every Quantitative Test NOTE: Watch Out for 3 or More Drug Screenings Performed Every Week on an Ongoing Basis. 58 Treatment Center Paid Upfront for Services Treatment Center Bills Payer at Higher Cost NOTE: The Treatment Center May Reimburse Member for Expenses. 59 Sober Homes Team Up With Programs Covered by Insurance Professional Patients 60 20

21 Billing Lower Level (Non-Residential) Services 61 TOXICOLOGY BYPASS PAYERS How Do These Schemes Get Past the Payers? Bypass Payers Controls 62 FORENSIC INVESTIGATION Critical Suggestions for Quantification/Validation & Essential to the Process External Sources of Information Provider s Web-Site 63 21

22 FORENSIC INVESTIGATION Critical Suggestions for Quantification/Validation & Essential to the Process External Sources of Information (Cont d) Secretary of State State Department of Corporations 64 FORENSIC INVESTIGATION Critical Suggestions for Quantification/Validation & Essential to the Process External Sources of Information (Cont d) CLIA Certification 65 FORENSIC INVESTIGATION Critical Suggestions for Quantification/Validation & Essential to the Process External Sources of Information (Cont d) Licensing, Credentialing & Regulatory Boards 66 22

23 FORENSIC INVESTIGATION Critical Suggestions for Quantification/Validation & Essential to the Process External Sources of Information (Cont d) Google Earth 67 FORENSIC INVESTIGATION Critical Suggestions for Quantification/Validation & Essential to the Process External Sources of Information (Cont d) Google Search, in a Variety of Ways Reverse Search 68 FORENSIC INVESTIGATION Critical Suggestions for Quantification/Validation & Essential to the Process External Sources of Information (Cont d) Online Reviews Court Documents News Articles Patient/Member Interview(s) or Questionnaire(s) 69 23

24 FORENSIC INVESTIGATION Critical Suggestions for Quantification/Validation & Essential to the Process External Sources of Information (Cont d) Cost Analysis 70 TOXICOLOGY EXAMPLE 1CALIFORNIA AAA Substance Abuse Facility s Financial Agreement TREATMENT FEES AND COSTS Residential Detoxification $850 per day) Number of days: 3 $2, Days CORE Program ($49,000.00/$47,500.00*) $49, Money on the Books $ *Denotes discounted amount if total cost of treatment is paid upon Client s admission to AAA. For Example, Discounted cash price (payment by check/cashier s check) is $47,500 for Extended Care Program. 71 TOXICOLOGY EXAMPLE 1CALIFORNIA AAA Substance Abuse Facility s Financial Agreement (Cont d) Payment in Full. I will pay the full amount due in order to receive the above treatment program upon admission. A discounted cash price has been extended to me if I pay by cash/check/cashier s check. Total Cost of Treatment $ 51, Amount Expected from Insurance Carrier $ 49, Total out of pocket expense for Treatment Cost $ 2,

25 TOXICOLOGY EXAMPLE 1CALIFORNIA AAA Substance Abuse Facility s Financial Agreement (Cont d) Reality Check Billed The Payer Residential Treatment Charges (90 Days) 1002/BH R&B Res/Chem Dep $176, Laboratory Charges QW Drug Screen, Multiple Drug Classes $70, Outside Toxicology Multiple Quantitative Laboratory Panels $164, GRANDTOTAL BILLED $412, TOXICOLOGY EXAMPLE 2 FLORIDA HCPCS Code #H0018 is Defined As: The H codes are used by those state Medicaid agencies that are mandated by state law to establish separate codes for identifying mental health services that include alcohol and drug treatment services. Behavioral health; short-term (30 days or less) residential (nonhospital residential treatment program), without room and board, per diem. 74 TOXICOLOGY EXAMPLE 2 FLORIDA Facility/Patient Agreement I understand that as a courtesy, BBB will bill my insurance company per our standard per diem rates of $1, for Residential Treatment, $ for Day/Night Treatment, $ for Intensive Outpatient Services and $200 per hour for Outpatient Services

26 TOXICOLOGY EXAMPLE 2 FLORIDA Reality Check Let s Talk! Payer Was Billed ~$250, for 45 Days of Residential Care & Urine Toxicology Testing VS Patient Agreement Rates Should Have Been $66, VS Cash Payment/Uninsured Amount Would Have Been $18, TOXICOLOGY RESOLUTION Pro-Active Recommendations Perform an Analysis on Plan/Policy Language 77 TOXICOLOGY RESOLUTION Pro-Active Recommendations Identify Through Pre- & Post-Payment Claims Edits Medical Policy Edits Coding Edits External Sources NOTE: Definitely Pre-Payment is the Best Method 78 26

27 TOXICOLOGY RESOLUTION Pro-Active Recommendations Modify Current Approaches Review All Substance Abuse Diagnoses (ICD-10) Prior to Payment Review All Substance Abuse Revenue Codes Prior to Payment Modify Authorization Requirements 79 TOXICOLOGY RESOLUTION Pro-Active Recommendations Modify Current Approaches Educate Claims Staff Individuals Responsible for Pre-Certification Case Managers Medical Director/Consultants Customer Service Individuals NOTE: Customer Service is Your Front-Line Defense 80 TOXICOLOGY RESOLUTION Pro-Active Recommendations Modify Current Approaches Identify & Review All Related Interim Billings Spikes in Billings and/or Payments Spikes in Codes NOTE: It is Essential to Continually Modify Your Approaches, as the People Gaming the System Will

28 TOXICOLOGY RESOLUTION Pro-Active Recommendations Perform or Outsource Forensic Type Review Negotiate Only on the Payment of Eligible/Documented Services Inclusive of All Services/Providers of Services With Extreme CAUTION 82 TOXICOLOGY RESOLUTION Pro-Active Recommendations Use Reviewers Who Are Familiar with the Scams in the Industry Utilize the Plan/Policy Language in Order to Determine Whether Services are Eligible Read Between the Lines Are Able to Quantify 83 TOXICOLOGY RESOLUTION The End 84 28