According to the Washington Post “many treatment centers do not follow-up with their patients. Their ‘100 percent’ success rate that are cited only applies to those who complete the length of their stay. Even those who boast a more modest ’30 percent success rate’ only draw that figure from sobriety rates after treatment, not from six months for three years down the road.”
Traditionally, behavioral health has been on the “back burner” for assessment and treatment. New data indicates a direct link between behavioral and physical health. Primary care physicians often “shy away” from evaluating behavioral health as the “root cause” of a chronic disease. Policymakers and providers alike recognize the need to allocate more resources for behavioral health and substance abuse prevention, but also the urgent need to redesign patient treatment plans to “treat the whole patient.”
Behavioral treatment centers provide inpatient and outpatient services to individuals who find themselves in need of receiving inpatient care for mental, behavioral, and/or substance abuse concerns. Inpatient treatment provides those in need of stabilization and crisis resolution with a safe environment in which to jumpstart their recovery process. Facilities utilize Google Ads for ease of “selling services” to potential patients and families in their search for treatment facilities. Some facilities offer yoga, massage therapy, horseback riding, and of course, traditional onsite therapists.
For several months I have been trying to reconcile medical billing for inpatient admissions to several Georgia behavioral health facilities. The results of my research have been “eye-opening” and “alarming.” The information below was extracted from the State of Georgia website:
Rules of Georgia Department of Community Health Healthcare Facility Regulation Chapter 111-8-19 Rules and Regulations for Drug Abuse Treatment and Education Programs – Effective Date 29September2013
111-8-19-.10 Staffing. (1) The program shall have sufficient types and numbers of staff as required by these rules to provide the treatment and services offered to clients and outlined in its program description.
(2) Staff subject to professional practice acts must be in compliance with the state practice acts.
(3) Counseling services are provided by individuals qualified by education, training, and experience to provide substance abuse counseling and who are licensed/certified if required by state practice acts.
(4) The medical responsibility for each client will be vested in a licensed physician who oversees all medical services provided by the program. Physician assistants or nurse practitioners may be utilized to the extent allowed by state practice acts.
(5) Each program shall have available professional mental health consultation to review selected cases and to provide assistance to the staff in client management or for referral for psychiatric services.
(6) The clinical director must be either a doctor of medicine licensed to practice in this state, or a licensed practitioner who is licensed to provide treatment, therapeutic advice or counsel for the rehabilitation of drug dependent persons in compliance with state practice acts, or a certified addiction counselor.
(7) For any employee hired after the effective date of these rules, employment and criminal background checks shall be conducted prior to employment, and only persons with no history of violence or abuse which would pose a risk to the clients in treatment shall be employed by the program.
(8) Staff Training and Orientation. Prior to working with clients, all staff who provide treatment and services shall be oriented in accordance with these rules and shall thereafter receive additional training in accordance with these rules.
In the state of Georgia a licensed physician is NOT required to be onsite or personally examine patients on admission to behavioral therapy treatment centers. “111-8-19-.10 Staffing 4.0 The medical responsibility for each client will be vested in a licensed physician who oversees all medical services provided by the program. Physician assistants or nurse practitioners may be utilized to the extent allowed by state practice acts.” Simply, a physician’s assistant or nurse practitioner may assess patients to the extent allowed by state practice acts. The institutional Clinical Director is required to be a “doctor of medicine licensed to practice in this state, or a licensed practitioner who is licensed to provide treatment, therapeutic advice or counsel for the rehabilitation of drug dependent persons in compliance with state practice acts, or a certified addiction counselor.”
Georgia facilities primarily utilize Physician’s Assistants (PA-C) and Nurse Practitioners (NP) for patient evaluation and assessment. Facilities generally have ONE PA-C or NP on staff to oversee care for 50 or more inpatients (Ratio 50:1). Physician’s Assistants (PA-C) and Nurse Practitioners (NP) have medical licensure that allows them to write prescription medications, with some limitations dependent upon each state’s requirements. Both PA-C’s and NPs should discuss a patient with the managing physician; however, this is not strictly enforced. The ongoing expansion of responsibilities for physician assistants and nurse practitioners is renewing opposition from physician groups. In February 2019 the American Medical Association published the summary below as key risk indicators.
- This year, the National Commission on Certification of Physician Assistants expects more states to relax restrictions on PAs and nurse practitioners.
- Physician groups such as the American Medical Association are adamantly opposed to PAs and NPs practicing without physician supervision.
- A new physician group formed last year—Physicians for Patient Protection—is seeking to turn the tide on regulatory changes for PAs and NPs.
Average cost of inpatient behavioral treatment admission in Georgia ranges from $1800-$2800 per day. Monthly bill for a 30 day admission costs $54,000 to $84,000. “Danger signals” were identified during client discussions after inpatient admission, medical billing review and negotiation, and medical records requests/review with clients. From experience here’s a look at the past twelve months in the state of Georgia for clients in my advocacy practice.
- Initial inpatient behavioral therapy admission MAY be approved for up to 30 days, dependent upon the reason for admission.
- A Clinic Medical Director would need to discuss the patient with the insurance company AFTER 30 days to request additional admission days. (Remember, this patient may have NEVER be evaluated by a physician at a Georgia facility.)
- Substance abuse concerns were the most rapid insurance approvals, especially for alcoholism and drug addiction.
- Outside medical records were NOT requested from patients’ primary care physicians nor from any prior admissions – including behavioral therapy admissions.
- “Intake” at the facility was a verbal discussion and documentation based on the discussion with the patient being admitted. If a patient was transported from an Emergency Room or correctional facility, those medical records may have been provided. Family members, when available, were not interviewed during or immediately after the admission process to verify or confirm accuracy of information provided at “intake.”
- Patients failed to disclose prior admissions for mental, behavioral, and/or substance abuse evaluation. Historical information is critical to patients admitted for suicidal ideation, depression, and substance abuse.
- “Intake” data and initial onsite staff evaluation was used as the baseline to develop the patient treatment plans for admission.
- Medical records requests for itemized, detailed billing statements to include ICD and CPT codes have been ignored – some for greater than 12 month.
- Patients who did not participate and meet the established metric for defined treatment program at the facility, primarily attending group and individual therapy sessions, are informed at discharge that their insurance will NOT pay for the admission.
- 70% of patients were re-admitted to a second inpatient behavioral treatment facility within 12 months of discharge.
A national crisis exists for treatment failure at behavioral therapy treatment centers. Some people blame the patient – others blame the healthcare system. America has the most expensive healthcare system in the world. According to the CDC over 45 million adults live with a mental illness; however, as many as 60% don’t receive treatment in a given year. This is another critical issue within America’s failing healthcare system and an American Healthcare 911 – behavioral therapy treatment centers.