As I was enjoying time with friends and family last night in Boston, I was asked the following question by a woman who is a Chief Healthcare Economist for The Office of Inspector General, US Department of Health and Human Services:
How do we get rid of the fraud and abuse in the substance use treatment industry, particularly with the atrocities happening in many sober homes and the over prescribing of medically unnecessary (and addictive) drugs which are being prescribed to some of societies’ most vulnerable citizens (addicts)?
The AIG recently participated in the largest health care fraud enforcement action in Department of Justice history. Hundreds of people were charged across multiple states involving over 1 billion dollars in fraudulent claim filings. In one noteworthy fraud scheme, a medical professional in Texas was charged with over-prescribing medically unnecessary narcotics to patients, some of whom died from drug overdoses. The doctor allegedly fraudulently billed Medicare and received more than $1.2 million in reimbursement. READ HERE for some quick facts on the action, and HERE for the official press release from the DOJ.
As I was thinking about how to answer this question to this woman who is probably 20x more intelligent than I am, what did come to mind is something along the lines of…. “It is no wonder insurance companies put us (as providers) through such rigorous and time consuming scrutiny in the form of questioning just about every decision we make and every action we take. All we are doing is trying to get what we often feel is the bare minimum amount of coverage for our patients and provide them with the best possible care, and yet they don’t ever seem to be on our side….”
For sure much of the intense scrutiny we get as providers in behavioral health is due to a lack of parity, stigma and shame and the misguided belief by some that addiction is a choice rather than a disease. However, much of it is also due to the fact that there are alot of really bad people out there capitalizing on our nation’s drug addiction epidemic by committing crimes and grossly taking advantage of very sick and vulnerable people. And insurance companies are dead smack in the middle of it.
Patient brokering, providing services and products that people not only don’t need but which are also potentially deadly for them and falsely billing for products and services that aren’t provided are serious crimes and serious ethical breaches. We should not be surprised that these same insurance companies who are victims to this kind of abuse are also the ones giving us what often feels like an unnecessary and unappreciated fight over providing the appropriate level of care for the appropriate amount of time based on our clinical recommendation as legitimate and trustworthy providers. Their eyes and ears have to be wide open. They don’t trust anyone. It makes sense, and it is extremely bad for those of us who are actually doing the right thing.
More importantly, the fraud and abuse is bad for patients. They are the ones who are hurt the most by this high level of distrust between payer and provider. They suffer because of the actions of a few really bad people. It is not right and it is not fair. They deserve more and better from the entire industry.
While I try my best to answer this question posed last night, I will say to the majority of us who are playing by the rules and in this for the right reason that the next time a UR rep from an insurance company makes us question why we come to work every day, try to have an ounce of compassion for them! Do continue to advocate and fight aggressively and passionately for your patients. Do not allow discrimination for what we know are treatable diseases to go unspoken. Call it for what it is and settle for nothing less than what your patients need. Fight the stigma and the shame. Prove to them that there is value in what we do! After all, there is value and recovery is possible. Many just don’t know it or believe it.
And understand that the sooner this fraud is eliminated, the sooner we can all work together to achieve our goals. The ideal scenario is payer and provider trust one another and can work together to achieve a similar goal that is in the best interest of the patient. Second to that is just being able to trust one another. Without some level of trust, we will never get anywhere. And we won’t have trust until this nonsense such as the Del Ray, Florida Sober House scene gets cleaned up once and for all!
Thank you Marta and Leemore for inspiring us to think about this issue, and thank you Kim and the whole team at SCH for working effortlessly as we try to make a difference in this world in the work we are doing.
