Knowledge and Insights

Opioid use and addiction have reached epidemic proportions in this country.  According to the U.S. Centers for Disease Control and Prevention, in 2016, an average of 115 Americans per day died from an opioid overdose,¹  leading President Trump to declare a Public Health National Emergency in October 2017 and set goals to address the issue. The U.S. Centers for Medicare and Medicaid Services (CMS) also have declared the opioid crisis a high priority and developed plans to deal with it. Various federal and state regulatory agencies, such as the Office of the Inspector General, have been updating and increasing the pressure on compliance with the already-inherently-complex rules and requirements applicable to organizations in the behavior health sector. On October 24, 2018, President Trump signed bipartisan opioid legislation, The Support for Patients and Communities Act, further demonstrating the urgency of addressing this epidemic.

What does all of this mean to you and your organization?

Behavioral health agencies throughout the country will continue to be impacted – from administrative, financial and compliance perspectives – by the increased public and regulatory focus on the opioid issue. They, particularly those providing substance abuse treatment programs, can expect heightened scrutiny and increased risks of reviews or audits by state and federal governmental agencies.  In fact, regulators’ usual interest has turned microscopic and the pace stepped up for agencies to prove that they are meeting documentation, billing and deadline requirements, while undergoing more intense programmatic and compliance audits. As a result, the top priorities for your organization should include:

• Understanding and anticipating the impact of these trends – ensure managers, staff and departments are educated on relevant external issues, trained on internal programs and prepared to meet operational challenges;
• Implementing or improving procedures and controls to ensure compliance with all updated federal and state rules, regulations and deadlines;
• Monitoring how your organization is handling changes, both regulatory and internal; and
• Maintaining a program of compliance.

Organizations that provide substance abuse services will be at the top of the list for audits. Therefore, it is crucial to have a sound internal control system in place and to monitor compliance with your programs on an ongoing basis. If an agency has a weak internal control system or issues with noncompliance, the consequences could be severe and include:

• Significant penalties and fines
• Poor management decisions
• Occurrence of fraud
• Sanctions (i.e., holds on billing)
• Damage to reputation
• Termination of funding
• Legal exposure and costs
• Failure of external audits or reviews leading to payback of unsubstantiated claims
• Shut down(s) of program(s) and/or organization

What can you do to limit or prevent these consequences?

Any one of the above would place significant additional financial and administrative burdens on an organization, weakening operations and focus, which should be on serving your constituents and achieving your mission. By providing the following services, Mercadien has helped behavioral health and nonprofit organizations achieve not only compliance, but also efficiencies, while navigating the intricacies of the increasingly complicated regulatory landscape:

• Assistance with Fee-For-Service transitions from the contract reimbursement billing model
• Internal audits
• Monitoring compliance with rules and regulations, including identifying weaknesses and opportunities for improvement
• Audit preparation
• Internal control evaluation reviews
• Risk assessments

Our extensive knowledge and experience in auditing, accounting and regulatory compliance has benefited hundreds of clients in this sector, which Mercadien has served for 35 years. Because our professionals have performed engagements on behalf of both NJ Medicaid and behavioral health agencies, we have direct knowledge of the unique, myriad rules and regulations of the various state Medicaid programs, and understand the needs and workings of nonprofits.

If you would like to discuss your organization’s audit needs, compliance programs or regulatory or other concerns, please feel free to contact me at (609) 689-2333 or [email protected].

1 – Statistic from https://www.cdc.gov/mmwr/opioid_reports.html; Opportunities to Prevent Overdose Deaths Involving Prescription and Illicit Opioids, 11 states, July 2016-June 2017; Weekly / August 31, 2018 / 67(34); 945-951