Outpatient Insurance practice without controlled substances

[sweetlenovo88]

What are your thoughts on filling such a practice in a shortage area with private insurance? No stimulants. Thereby no ADHD patients at all and any patients already on a benzodiazepine will be referred to their PCP to continue benzo treatment or detox off with the PCP. No controlled hypnotics-patients will be switched to other agents or PCP will continue.

I am estimating this would cut the patient pool by about 25%. (ADHD patients, and those not willing to get benzos from PCP, or those on benzos without a pcp).

Would this be a problem from referral sources like PCPs I wonder

Thoughts?

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[Shikima]

What are your thoughts on filling such a practice in a shortage area with private insurance? No stimulants. Thereby no ADHD patients at all and any patients already on a benzodiazepine will be referred to their PCP to continue benzo treatment or detox off with the PCP. No controlled hypnotics-patients will be switched to other agents or PCP will continue.

I am estimating this would cut the patient pool by about 25%. (ADHD patients, and those not willing to get benzos from PCP, or those on benzos without a pcp). Thoughts?

Sounds good to me. Drawing a line in the sand.

 

[NickNaylor]

What’s the motivation in cutting out all controlled substances from the get-go? Seems a little heavy-handed, no? Trying to avoid medication-seeking patients? Don’t have to have discussions about controlled substances?

Just seems like an unnecessarily heavy handed move and doesn’t take into account the small number of patients who might very well need these agents. I guess the response would be to send them somewhere else and, from a business perspective, that population likely wouldn’t hit your bottom-line. But what if you’re treating someone who isn’t responding to first-line agents (I’m thinking of anxiety specifically) and you’ve gotten to the end of the line with non-BZD treatments. Are you just going to give them the boot?

 

[sweetlenovo88]

What’s the motivation in cutting out all controlled substances from the get-go? Seems a little heavy-handed, no? Trying to avoid medication-seeking patients? Don’t have to have discussions about controlled substances?

Just seems like an unnecessarily heavy handed move and doesn’t take into account the small number of patients who might very well need these agents. I guess the response would be to send them somewhere else and, from a business perspective, that population likely wouldn’t hit your bottom-line. But what if you’re treating someone who isn’t responding to first-line agents (I’m thinking of anxiety specifically) and you’ve gotten to the end of the line with non-BZD treatments. Are you just going to give them the boot?

Some patients will be seen with telemedicine and the federal Ryan Haight act does not allow controlled prescribing if not seen in person for an initial visit. I want to avoid the red tape and liability

 

[NickNaylor]

Some patients will be seen with telemedicine and the federal Ryan Haight act does not allow controlled prescribing if not seen in person for an initial visit. I want to avoid the red tape and liability

Gotcha, that makes total sense in that case.

 

[dl2dp2]

You will fill easily. And the entire country is a "shortage" area. Problem is, this doesn't get away from the problem having to deal with 15 min med checks, low insurance reimbursement, major paperwork/billing/credentialing burden, and a small number of difficult patients with chronic suicidality and personality disorders taking a lot of your time.

IMHO the refusal to treat with controlled substances will be a barrier for more efficient practice. The need for controlled substances in and of itself is not an indicator of more time or complexity of the case as the other poster observed.

Ryan-Haight can be bypassed as long as you see the patient once in the clinic.

IMHO it's a lot easier if this is the lifestyle you want to work with a few other MDs and do a group model. Your patient load will very quickly explode in a way that is very inefficient for a solo. Of course, you can do this while filling a cash practice on the side at a different location.

 

[digitlnoize]

Some patients will be seen with telemedicine and the federal Ryan Haight act does not allow controlled prescribing if not seen in person for an initial visit. I want to avoid the red tape and liability

This is not a clear cut legal issue. There is a LOT of telepsychiatry being done that involves controlled substances that does not meet Ryan Haight standards (which are insane). This is even being done at federal centers (VA's, Indian Reservations, Bases, etc). The biggest issue is that most state's laws (and the medical literature) define real-time video conferencing telemedicine as equivalent to an in-person visit. The Ryan Haight Act fails to recognize this, but it's never been challenged in court. Second, the Ryan Haight Act does allow for telemedicine prescribing of controlled substances if various situations occur, which are possible, including that there is a prescriber with a DEA number available at the other end of the connection, or that the facility has it's own facility DEA number (which most community mental health centers could get if they wanted).

Regardless, while I understand people's reticence about it, literally thousands of telemedicine stimulant prescriptions are being written daily and the DEA reps I've talked to (in many states) have no plans to enforce any laws to make that stop. Opiates maybe, but not legitimate stimulants for ADHD if you're not running a pill mill.

 

[TexasPhysician]

Second, the Ryan Haight Act does allow for telemedicine prescribing of controlled substances if various situations occur, which are possible, including that there is a prescriber with a DEA number available at the other end of the connection, or that the facility has it's own facility DEA number (which most community mental health centers could get if they wanted

That 2nd part is not correct. The facility needs to obtain a special registration with the DEA, not just a DEA number. Ryan Haight did this, but the political geniuses never established a committee to review and provide special registrations.

If you are involved with Indian Health Service, there is an exception. If a prescriber is already present on-site, you are good. True detention centers were given a special registration with the DEA.

The problem is that special registrations were automatically given at the beginning, but they are not able to process or provide applications.

Prescribing controlled substances without an exception is a federal violation that could result in loss of your license. It isn’t enforced currently just like the marijuana business. Will the government ever change its stance and enforce? Who knows?