Compliance and Risk Issues in Addiction Treatment Reimbursement

Zachary Rothenberg, Esq., Healthcare Attorney at Nelson Hardiman, LLP

John A. Mills, Esq., Healthcare Attorney at Nelson Hardiman, LLP

September 15, 20171

Disclaimer

➢ General discussion, not specific legal advice

➢ No attorney-client relationship

➢ Seek legal counsel in applicable jurisdiction

2

Roadmap1. Compliance 101

2. Insurance reimbursement: Identifying Pitfalls and Developing Best Practices

3. Patient financial responsibility and other risky referral practices

4. SIU: What to know about payor audits

5. Takeaways

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1. Compliance 101

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A framework and practical perspective on compliance

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7 Elements of a Compliance Program

WRITTEN COMPLIANCE POLICIES AND PROCEDURES

DESIGNATED COMPLIANCE

PROFESSIONALS

EFFECTIVE TRAINING OF ALL

STAFF

EFFECTIVE COMMUNICATION

PREVENTATIVE AUDITING AND MONITORING

ENFORCEMENT OF STANDARDS

PROMPT RESPONSE TO POTENTIAL COMPLIANCE VIOLATIONS 6

Compliance as a Process, Not a State of Being

Program Assessment

• Assess compliance programming already-in-place.

• Identify areas for improvement and risk concern.

• Present findings through confidential memoranda and discussions with governing board and senior management.

Compliance Plan

• Develop strategic plan tailored to organization’s specific business and regulatory needs.

• Continuous monitoring and reporting• Updating of compliance plan, policies

and procedures to address emerging risk areas and new regulatory developments.

Ongoing Work

• Auditing - Validation• Allowance of anonymous

complaints 7

• Workforce Screening and Training• Building organizational culture of

transparency and accountability

Distinguishing the Complianceand Legal Functions

Legal Counsel

• Legal Function• Job: Advise on legal risks and

threats• Ethical duty to give sound legal

advice and to represent client’s interests “zealously”- focus on success in legal battles

• Focused on protecting attorney-client privilege to shield sensitive information

• Define/establishing appropriate company standards

• Communication limited to senior management

Compliance Officer

• Management Function• Key job: Do what it takes to detect

and prevent misconduct• Translate legal advice into

management action • Focus on preventing mistakes • Supports implementation and

monitoring process to ensure standards are being met.

• Direct reporting to CEO and Board• Discoveries not protected by

privilege• Communication with entire

workforce 8

Spectrum of Approaches to Compliance

What’s the least we need to do to demonstrate a bad actor went rogue and minimize risks of government investigation /

whistleblower complaint / lawsuit?

versus

How do we measure and advance our organizational mission, vision, and strategy via data and culture of compliance?

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2. Insurance Reimbursement: Pitfalls and Best Practices

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An Evolving Regulatory Landscape for

Addiction/Behavioral Health• State-to-state variation

• Evolving treatment models (from social model to medical)

• Evolving approach to evidence-based standard

• Evolving reimbursement models

• Evolving regulatory categories (from siloed regulation to integration in healthcare/residential care)

• Evolving view of treatment components (services beyond med-surg healthcare)

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An Evolving Insurance Claims Battlefield

• Increasing levels of audits and investigations

• Fraud, waste and abuse enforcement

• data sharing -coordination and collaboration among private payors and also among federal and state agencies/payors

• data pattern detection (referral relationships)

• data mining and mapping (development of algorithms to identify problems; preventive analytics)

• scrutiny of claims and encounter data (provider and recipients, coding, service descriptions, documentation)

• Increasing level of special investigation reviews 12

An Evolving Payor Mindset about Coverage

• Rapidly changing standards of coverage and medical necessity for

• UDT

• Setting of Care

• Length of Residential stays

• Length of Outpatient program participation

• Documentation requirements

13

Different Rules for Different Payors

14$

Medicare

Provider

Bill Cigna(Fully

Insured)

Cigna (Admini-strative Service

Org)

ERISAPlan-

Driven

Patient

Patient

Tx

$

Tx

$

Allowed Amount

Or TPA

Fully Insured Plans

Self-Funded Employer Plans

Federal Health Programs

State Law Driven

Federally Regulated

Provider

Medicaid Tricare

Recent Trends

• Growing number of large payors (Anthem, Blue Shield, Health Net, Aetna, Cigna, United) alleging fraud and abuse

• Targeting behavioral healthcare facilities

• Special Investigations Unit (SIU) investigations and task forces

• Recoupment of fees

• Referrals to State licensing agencies and criminal prosecutors 15

Why does this matter?

• Payment of claims will be delayed during SIU investigations

• Payors may recoup previous payments and/or suspend payments to treatment programs

• Lawsuits and criminal liability

• Out of business

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Key Terms in the Reimbursement Minefield Fraud: intentional deception/misrepresentation made by a person

with the knowledge that the deception could result in some payment to which provider is not entitled

Abuse: provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost or reimbursement for services that are not medically necessary or that fail to meet professional recognized standards

Waste: provider practices that incur unnecessary costs as a result of deficient management, practices, or controls

Overpayment: excessive payments to providers that would not have been made but for some error on the part of the provider or the payor (no intentionality) 17

Risks to address before the claim is submitted

• Plan Coverage Criteria

• Medical Necessity Standards: ensuring that the treatment is clinically appropriate for the patient within professional standards

• Accuracy of the claim/code

• Sufficiency of Documentation: ensuring that the medical record supports the treatment rendered

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Preauthorization / Verification of Benefits

• In some cases, payors have tried to demand repayment of fees already paid for services delivered because the payor discovered that the provider was not licensed, certified or accredited

• Is a payor would be unjustly enriched if allowed to recoup amounts paid in instances where the defect in the claim was technical?

• Payors cannot be forced to pay unpaid claims on the same basis as they can be denied recoupment and have more leverage to demand changes

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Documentation

• Billing should always be consistent with Services rendered and Clinical Records:

• Documentation of services in patient’s medical record

• “Demographic information” (service address, rendering provider, etc.)

• Services rendered to patient while in treatment

• Any deviation from above is considered fraudulent and may not be reimbursed.

• Services-Authorization mismatches can trigger records requests

• Better to know ahead of time

• Daily individualized notes signed by rendering provider(s)

• Medical necessity

• Documentation is your “evidence”!20

Risks Related to the Billing of the Claim

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• Unbundling: when a provider submits bills in a piecemeal or fragmented fashion to maximize the reimbursement for various tests or procedures that are required to be billed together.

• Coding Accuracy: correct HCPCS Revenue Code?

• Upcoding: occurs when a provider intentionally uses a higher-paying code on a claim form for a patient to fraudulently reflect the use of a more expensive procedure or device than what was actually used or was necessary.

• Forensic billing?

Practices that Raise the Risk of Claims of Fraud and Abuse✓Procurement of insurance policies for individuals

✓Payment for housing and travel for individuals

✓Failure to collect fees, deductibles, copays, and coinsurance

✓Charging of inconsistent rates to different payors for treatment services

✓Insufficient documentation

✓Medical necessity✓Proof of payment of fees, deductibles, copays, and

coinsurance

✓Family members or co-workers with same plan 22

When to fight and when to fold?

• Enlisting patients as allies

• Being prepared for an increasingly contentious payment process and the need for appeal competency and contest claims payment

• Diversifying payor mix to minimize risk of overexposure to one bad relationship

• Evaluating in-network versus OON status 23

Tips for Providers• Verify benefits.

• Make sure billing is always an accurate reflection of services provided.

• Understand payers’ expectations for the services you bill.

• Keep ancillary billing to a minimum – Avoid over-utilization.

• Hire medical records personnel – Create internal controls (routine audits).

• Familiarize staff with payers’ expectations and implement policies and procedures to ensure documentation is up to par.

• Consider clinical utility of drug tests and how they contribute to outcomes.

• Understand different types of drug tests and when they are necessary.

• Collect deductibles up front, make reasonable effort to collect co-pays and balance bill on back end.

• Ensure that all agreements obligate the patient to pay for services that are not covered by insurance

• Implement sound policies and procedures for scholarships and other forms of financial hardship assistance.

• Maintain consistent documentation in everything you do.

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3. Waiving Patient Financial Responsibility and Other Risky Referral Practices

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Addiction treatment marketing in the media lately . . .

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. . . has not been good news . . .

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“Marketers charged in drug rehab urine testing scheme . . .”

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“FBI probes misuse of nonprofit in drug rehab patient recruitment”

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When does legitimate marketing . . . . .

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. . . devolve into kickbacks?

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Key Terms

• Kickback: giving or receiving anything of value to induce

referrals of patients, goods, and services

• Self-Referral (health professionals): referring a patient for

goods or services in which the MD or family member has a

financial interest (compensation or ownership)

• Running/Capping/Steering: paying marketers to recruit

patients on a per patient basis or based on recruitment32

Key Concepts

• FMV (Fair Market Value)

• Commercial Reasonableness

• Paying for the Value or Volume

of Referrals

• Inducement

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“We don’t get to pick and choose which laws we like.”

Federal Health Programs

Commercial

InsuranceCash Pay

Federal Law

Anti-Kickback Statute

StarkFalse Claims Act

State Specific Laws

-Healthcare laws

-Insurance-focused laws

-Industry-specific laws

Federal Anti-Kickback Statute/ Safe Harbor / Personal Services Contract

(i) Written (ii) 1 year (iii) detailing services and (iv) schedule of delivery, without any (v) illegality in a (vi) commercially reasonable relationship at (vii) fair market value (FMV) not counting referrals 35

Many preexisting healthcare anti-kickback laws don’t address drug rehab-marketer relationships

Addiction treatment marketing as a “red-headed stepchild” from the perspective

of regulators and payors

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But plenty of reason to worry about rough waters ahead

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Existing laws offer ample ways to prosecute insurance fraud (e.g. Cal. Ins. Code § 750)

Anti-Capping/Steering Law

California Insurance Code Section 1871.7 makes it unlawful to knowingly employ runners, cappers, steerers, or other persons to procure clients or patients to perform or obtain services or benefits under a contract of insurance.

What makes someone a runner or capper?

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“Employment of a person or persons…to procure clients or patients to perform or obtain services or benefits ... that will be the basis for an insurance claim.” (State ex rel. Wilson v. Superior Court, 227 Cal.App.4th 579 (2014))

Florida’s new “Practices of SAS Providers Act”

• Criminalizes deceptive marketing practices by service provider, recovery residence operator, or advertiser/marketer

• Criminalizes misleading info re: identity, products, goods, services, or location of licensed provider

• Expands prohibition on any benefit to induce patient referral

• Enhanced penalties for higher volume of patient brokering

• New licensing of substance abuse marketing services

• Prohibits referrals by uncertified sober home to licensed provider39

Enforcement

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John Dudek, charged with receiving kickbacks from a drug treatment center for brokering patients from his sober home.

Source: Palm Beach Post, Nov. 19, 2016

http://www.mypalmbeachpost.com/news/news/crime-law/third-sober-home-official-arrested-on-patient-brok/ntBQm/

Looking AheadExpect more addiction marketing-targeted legislation in the future

Recent Florida laws as

a harbinger

Addiction-specific anti-

kickback laws

Body-brokering laws

Anti-discounting laws41

False Claims Litigation

• Insurance companies argue that providers whose claims are tainted by fraud and abuse are submitting “false” claims.

• State False Claims Laws– State laws prohibits the preparation and/or submission of false claims for payment to private insurers.

• Whistleblowers have financial incentive to report health care fraud –entitled to a portion of any recovery.

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““Referral” “Advertising”

1. Pay for advertising, not patients2. Don’t work with people who

pay for patients

3. Kosher structure + pay for marketers

• Pay for services (time/skill/effort) not success

• W-2 vs 1099? Bonuses?

• Commercial Reasonableness/FMV44

4. Use service contracts correctly

• Legitimate service relationships with referral sources

• Contracts to mask illegality are useless or worse

• Does it pass the straight face test? Smell test? Multiple lawyer test?

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5. Be Careful not to make dumb mistakes that mislead

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“Enjoy privacy and concierge service at our exclusive resort pool during your romantic getaway.”

6. Don’t Be An Ostrich

Providers need to:

• Know how to recognize fraud.

• Be proactive in combating fraud.

• Conduct internal audits.

• Investigate and strongly consider disclosing overpayments.

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Specific practices targeted as being fraudulent

•Procurement of insurance

•Patient financial responsibility

•Gifting

•Call centers

•Bed vouchers

•UDT48

Procuring Insurance• Insurers have been investigating “gaming” behavior with exchange-based

insurance plans:• Applications for insurance with a new address inconsistent with their

previous available address data; • At an address linked to an addiction treatment provider or sober living

facility; • With a policy paid for by someone unrelated who appears to lack a

personal connection and insurable interest; and • The policy only paid and maintained for as long as treatment is needed.

• CMS investigating practice of “steering” consumers into exchange-based plans.

• Paying for insurance has been alleged to be a form of kickback (by inducing patients to choose the program).

• Educating patients on how to obtain insurance? 49

Waiving Patient Financial Responsibility as a marketing practice

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Not New

• Widespread practice of waving fees, deductibles, copays, and coinsurance

• Illegal under Medicare and in some states (e.g., Florida and Colorado)

• Insurers increasingly pushing back by alleging fraud and abuse

• Insurers targeting behavioral healthcare facilities

• Special Investigations Unit (SIU) investigations

• Recoupment of fees

• Referrals to State licensing agencies and criminal prosecutors 51

Why does this matter?

• Increased scrutiny and allegations of fraud and abuse by insurance companies means treatment programs that discount or waive fees for patients must be mindful of legal limits and plan carefully

• Many patients in treatment programs have limited financial means

• Treatment programs want to make their services available to those in need without risk of investigation or recoupment from insurance companies 52

Understanding Insurance Companies’ Fraud and Abuse Arguments

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➢Insurance companies argue that providers who waive or discount patient fees are committing fraud and abuse

➢Potential inducement of patient to attend program because a patient may choose a provider who waives/discounts fees over other providers

➢Misstatement of reasonable and customary fees and interference with contract between patient and insurance company

➢Form of deception because provider charges different rates to different payors

Which fees must be collected?

Deductible

Copay

Coinsurance54

Risks of discounting or waiving fees

Risks

SIU

Investigation

Recoupment

Lawsuit

Denial of Fees

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Practices that raise risk

➢Routinely offering discounts on fees to all patients

➢Routinely waiving deductibles, copays, and coinsurance

➢Charging of inconsistent rates to different payors for treatment services

➢Insufficient documentation56

When can programs reduce fees?

Financial Hardship

Prompt Payment

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Financial Hardship Waiver

58

➢Treatment programs may reduce patient costs for those who have limited financial means

➢Programs should adopt clear, consistent, and reasonable standards

➢E.g. Sliding fee assistance program policy

➢Patients should complete an application for assistance

➢Programs should collect documentation verifying income

➢If a patient qualifies for assistance, the program may

➢Discount or waive the deductible, copayment or coinsurance

➢Reduce fees according to the program’s set standards

Financial Hardship Waivers (cont.)

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Financial hardship waivers or “scholarship” programs will raise red flags if:

• Advertised

• Promised as part of a referral process

• Charges increased to offset waivers or discounts

• Failure to collect or attempt to collect from specific group of insureds for reasons unrelated to financial hardship (e.g., financial hardship waivers or scholarships given to all patients from a particular referral source)

Prompt Payment Discounts

Best Practices for Extending Prompt Pay Discounts:• Discount should be for “prompt payment”

after services have been rendered

• “Prompt” payment generally means payment received within 30 days of the date of the invoice• Invoice itself can offer the prompt pay discount

• Based on practices in other healthcare settings, discount should be commercially reasonable • 5%-10% of fees?

• Our view is that the discount should be applied to co-insurance and balance of the fee, not to the deductible 60

Strategies for Reducing Risk

✓Keep a record of all fees, deductibles, copayment and/or coinsurance received from patients

✓Keep a record of all invoices sent to patients and attempts to collect payment

✓Ensure that all agreements obligate the patient to pay for services that are not covered by insurance

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Strategies for Reducing Risk

✓Adopt a sliding fee assistance program policy

✓Train staff to answer questions regarding patient financial responsibility

✓Require an application for a reduction of fees

✓Collect proper documentation verifying financial hardship

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Gifting

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Call Centers

• Is it kosher to pay an outside call center on a per patient

“success fee” basis? Or have law enforcement just not gotten

around to this.

• Unqualified leads? Unproblematic. Once you start qualifying

(e.g. requesting and verifying insurance info)? 64

Bed Vouchers

• As a quid pro quo for an outpatient referral?

• As a rental for someone in need? 65

Urine Drug Testing

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What are the big UDT issues?1. Financial kickbacks for referring lab tests – paying marketers and referring

MDs or treatment centers

2. Tests not MD ordered based on medical necessity determination

3. Tests fail to meet medical necessity criteria

4. Lab not appropriately licensed/certified for tests performed

5. Labs violating anti-markup rules by marking up tests done by other labs

6. Non-financial inducements for referrals (such as point of care cups or

onsite collection services)

7. Physician self-referrals

8. Sham investment arrangements to camouflage referral arrangements

9. Billing and coding UDT inappropriately 67

Compliance Recommendations➢Documentation of a new patient record should include a detailed

history, appropriate physical examination, and treatment order – as MD would make with any new patient, that includes a signed order

➢Documentation of periodic follow-up visits and physician review of UDT results, including specific analysis of the implication of relevant results (not just circling or underlying relevant data), i.e. commenting on test results and any changes in treatment – to demonstrate that they are being used in an ongoing course of care, not just a one-time visit followed by “ad inifinitum” testing

➢Signed order and documentation of testing frequency tapering down over time with randomization and focus on risky points

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Compliance Recommendations• More proactive verification by labs of physician justification for testing, to

distinguish between reimbursable and non-reimbursable tests, to root out physician under-involvement threatening medical necessity

• For programs that wish to test more frequently than may be medically valuable from MD perspective, consider bifurcating between UDT that is physician-ordered and treatment-focused (and therefore reimbursable), as opposed to testing that is strictly for the chemical dependency program’s purposes to confirm abstinence irrespective of physician review (and therefore not reimbursable).

• If drug treatment centers and labs distinguished between these categories and limited insurance billing to genuinely doctor-ordered tests – charging patients directly for the deterrence and continued sobriety testing –would address fraud and abuse concerns

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Bottom Line• Not one size fits all but right and wrong ways to

market and work with marketers

• Deal with the “skeletons” in your closet

• Pivot from Fear-Driven to Strategic

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4. SIU: What to know about payor audits

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What is SIU?

• An SIU is a payor’s special investigation unit

• They identify and investigate organizations and individuals alleged by the insurance company to be engaged in fraud or abuse (including criminal)

• Special investigation units also inform consumers about the nature and prevention of insurance fraud

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The Growing Role of Data Analytics

• Payors and government are increasingly using data analytics and information-sharing to identify suspicious relationships and practices 73

Pre-Payment Vs. Post Payment

• Pre-payment / Post-payment reviews are based on assessment of clinical information to determine whether services were performed and are medically necessary, and comply with payor’s standards

• Pre-payment reviews take place before payment has been issued

• May lead to denial of claims

• Post-payment reviews generally happen after payment has been issued

• May lead to refund requests, further investigation and/or pre-payment review

• Not every records request means that a provider is in SIU investigation

• The effect of every SIU is not the same

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SIU Investigations

• Requires time to analyze claims, medical records and other data

• Can be developed through internal and external referrals, proactive claims data mining using fraud software through professional organizations, federal and state contacts

• Investigators and analysts are paired together to obtain medical records, analyze data, complete cases and final reports

• Medical records can be reviewed by the Medical Director and/or an external specialty medical consultant

• Often use third party reviewing companies incentivized to find errors 75

Time frames

• Pull and evaluate medical records, billing records, and policies immediately

• SIU time frames for submission are generally 30 days from the date of the letter

• Extensions may be granted

• After submission, review can take weeks to several months

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SIU Investigation Outcomes

• Subscriber / Provider Education

• Overpayment Recoupment

• Civil Litigation

• Provider Network Termination

• Subscriber / Group Termination

• Regulatory Agency and Law Enforcement Referral

• Criminal Prosecution

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Resolutions & Refund Requests

• SIU audits can take upwards of 6 – 9 months before there can be a determination or request for recoupment

• Audit findings detail all lines audited with a reason for each recoupment

• You can appeal and provide additional documentation

• May lead to refund request and involve legal negotiations

• When handled proactively, often resolved positively, with clearer expectations for both parties moving forward

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Major Risk Factors

Five risk factor areas of focus for SIU investigation:

➢Documentation Issues

➢Billing Issues

➢Patient Responsibility

➢Laboratory Services

➢Marketing/Kick-Back Issues

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Don’t Be Low Hanging Fruit

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Strategies for Responding to Audits

• Don’t ignore!

• Provide documentation showing bills and collections to date, even for dates of service that are prior to period of audit:

• Highlight deductible payments.

• Carefully explain policies and procedures for giving discounts.

• Point out that it is not reasonable for insurer to expect that provider has made collection efforts prior to claim being processed.

• Don’t sign verifications prepared by insurer without counsel’s review.

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Strategies for Responding to Audits (cont.)

• Using status of assignee or designated representative, request copies of plan documents, benefit summaries, insurer’s relevant protocols and guidelines, etc.

• Communicate with patient; invoice patient and get them involved.

• Keep careful track of timelines for responses, and do not hesitate to point out where insurer is duplicating its requests for information.

• Consider getting counsel to respond on your behalf, especially if audit is from SIU or corporate integrity department. 82

Strategies for Appealing Denials and Overpayments

• Make comprehensive appeal that is well-organized and persuasively written.

• Appeal should point out each of insurer’s potential violations and make good faith threats of legal action: • Unreasonably requiring proof of collection prior to adjudication

of claim.

• Untimely processing of claims.

• Refusal to provide requested documentation (and potential penalties under ERISA).

• Incorrect or bad faith interpretation of the plan, and potential breach of fiduciary duties.

• Arbitrary and discriminatory treatment in violation of federal and state mental health parity laws.

• Common law claims for services rendered. 83

Strategies for Appealing Denials and Overpayments (cont.)

• Using status of assignee or designated representative, request copies of plan documents, benefit summaries, insurer’s relevant protocols and guidelines, etc.

• Enlist patient as an ally.

• If self-funded ERISA plan, appeal to employers and threaten litigation against them.

• If individual policy, consider external review.

• Make reasonable collection efforts and highlight them to insurer; emphasize willingness to engage in commercially reasonable collection efforts.

• Don’t get bogged down in appeals while SOL runs out:

• Try to get “tolling” agreement.

• Consider getting counsel to respond on your behalf, especially if legal action is likely. 84

Strategies for Appealing Denials and Overpayments (cont.)

• Using status of assignee or designated representative, request copies of plan documents, benefit summaries, insurer’s relevant protocols and guidelines, etc.

• Enlist patient as an ally.

• If self-funded ERISA plan, appeal to employers and threaten litigation against them.

• If individual policy, consider external review.

• Make reasonable collection efforts and highlight them to insurer; emphasize willingness to engage in commercially reasonable collection efforts.

• Don’t get bogged down in appeals while SOL runs out:

• Try to get “tolling” agreement.

• Consider getting counsel to respond on your behalf, especially if legal action is likely. 85

5. Takeaways

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Out-of-Network Billing

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Out-of-network billing is not certain to remain a viable reimbursement strategy for addiction treatment programs over the next decade.

Integration

88

The distinctive nature of addiction treatment is likely to support a higher degree of integration into health systems than other forms of healthcare services.

Licensing categories

89

The licensing categories for addiction treatment are under pressure to change in many states as a result of pressure for greater uniformity.

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Worried About Committing Fraud When You Waive Patient Deductibles?

Stay Safe.

Patient Financial Responsibility Toolkit

• Prompt pay versus cash pay discounting• Application and program policy• Invoice & prompt pay discount template

• Model policies• Sliding fee assistant charts• Talking points for staff

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Why Join the American Addiction Treatment Association?

• Compliance requirements vary from state-to-state and are changing constantly, making it incredibly challenging to identify and implement the rules that apply to you;

• AATA is the only entity that tracks and organizes state rules and regulations in every state across the nation;

• It’s our mission to empower you through the vital information, resources, and industry connections you need;

• We offer ongoing, relevant, timely education that keeps you in the know, with presenters that possess unparalleled expertise in this field;

• You need to ensure that your facility is compliant with all requirements for licensure, certification, and accreditation;

• It’s crucial for you to clearly define your rights and responsibilities within those requirements;

• You need to maximize your time and therefore need to rely upon the most up-to-date information from experts specializing in and constantly monitoring the industry;

• We deeply believe in what you do…and we’re motivated to help you succeed!

www.addiction-tx.com888-958-2282

Questions?

92

Zachary Rothenberg zrothenberg@nelsonhardiman.com

John A. Mills

jmills@nelsonhardiman.com

www.nelsonhardiman.com

www.addiction-tx.com