Treatment Ethics Self-Assessment
If you are a treatment professional, here is a list of questions for you to consider when evaluating you or your program from an ethics and integrity stance:
Part of having a license or certification in the addiction or mental health field is all about making sure that it is renewed and that any continuing education units are obtained throughout your career. The requirements may vary by state, but this typically includes ethics units as well, and is an important way of staying current and ethical with your profession.
Scope of practice is your responsibility to limit your practice to areas in which you have been trained, educated, and licensed or certified. An example of working outside one’s scope of practice would be an SUD counselor recommending medications or actively treating (vs. referring out) an eating disorder.
A professional’s scope of competence changes over time and experience, but they should not hold themselves out as an expert in something they have no solid training in.
It is illegal in many states, and is unethical in all of them, to accept fees or to pay fees to anyone for the referral of a client. For example, California has Business and Professions code 650 that states:
“. . . the offer, delivery, receipt, or acceptance by any person licensed under this division . . . of any rebate, refund, commission, preference, patronage dividend, discount, or other consideration, whether in the form of money or otherwise, as compensation or inducement for referring patients, clients, or customers to any person, irrespective of any membership, proprietary interest, or coownership in or with any person to whom these patients, clients, or customers are referred is unlawful.”
There exists a massive corruption in the UA testing arena surrounding addiction treatment. We are seeing new examples [ link ] of this every day. In a typical residential treatment scenario, a client might be UA tested at intake with a complete toxicology report to determine what substances they have taken. Throughout treatment follow-up tests are rarely needed more than once per week except when substance use or medication irregularities are suspected.
Often UA testing gets billed out to insurance for exorbitant fees and is conducted on a highly frequent basis; making it a profit center for the treatment agency. Even toxicology labs partake in kickback money for treatment centers who send their UA testing to them to be billed large fees by the labs.
These are unethical scenarios and they abuse an already taxed health care system.
It’s not an ethical problem to mark up a diagnostic test to cover the cost of materials, testing, and staff to administer it, but there’s a difference between charging $900 (when the lab charges $6 for the dip panel and $25 for the lab result) for a simple dip panel confirm lab test, when $75 or $100 would be far more reasonable and appropriate.
Think about the motives when deciding to test. Is the motive income or clinical diagnostics?
Something that helps fuel the “body broker” problem, some treatment centers purchase insurance for an incoming client so that they can bill it for treatment. There are even examples where treatment centers “employ” the client as a means of getting them group coverage.
Of course this is not only unethical, but it also harms the client who completes treatment because the treatment center has no further motive to pay that health care coverage cost.
Often called, “The Florida Model” of treatment, this is the practice of bypassing state licensing requirements by setting up sober living homes in lieu of residential addiction treatment facilities and transporting patients to outpatient programs. This is all billed to insurance as outpatient services and the client is not charged for the sober living. This is widely considered to be illegal and unethical.
It leads to many ethical dilemmas because, in the majority of cases, insurance does not cover the cost of sober living, and the providing of free sober living to the client constitutes an inducement.
Some may think that they are doing a noble thing because many entering treatment do not have the money to pay for sober living, but just because something is done out of good intention does not mean it is ethical.
Here’s an article [ link ] about some legislation in Florida attempting (but not there yet) to solve this problem.
A common scenario here is that a call center contracts with a number of treatment agencies offering to send them inbound calls for a certain price. This creates a problem because someone calling to get treatment is supposed to be screened by a qualified professional and referred to the most appropriate facility for their particular needs, geographical location, and issues. But what happens is that they get sent to the place that pays the most for their call.
Many call centers also misrepresent the services being offered or the insurance coverage the inbound caller may have. They may even utilize keyword advertising on search engines; buying up keywords of ethical places but steering the caller to the ones that are paying for the referral.
As demonstrated by the recent press about Google’s problems with keyword advertising for addiction, there is much potential for shady dealing when marketing your treatment services on the internet.
Internet marketing is not a bad word, but it’s very easy to cross into unethical territory. If you want to do so while maintaining strict ethics you would want to buy keyword advertising that is transparent and honest, meaning that you wouldn’t be buying keywords for services you do not provide. You would not be buying keywords containing the name of other treatment centers (this, believe it or not, was/is a common practice). You would also make sure that your ad identifies who you are.
The American Society of Addiction Medicine (ASAM) gives us the standard criteria that are used by insurance companies and addiction professionals to determine the level of care that a client assesses for.
The screening of someone who assesses as needing residential level of care, but placement into a sober living and outpatient program (Florida Model) would constitute an inappropriate placement. An unethical treatment center might also “pad” utilization reviews with inaccurate information to get a client more time at a particular (higher) level of care so that they can continue billing for services that the client technically no longer requires.
It is illegal and unethical to offer clients inducements of value to get them into treatment. This includes, but is not limited to: air fare, spending money, cigarettes, and/or free or reduced cost sober living.
There’s no wiggle room here. It’s unethical.
It seems quite common these days that treatment centers are staffed with former “graduates” of their program. As a good measure, you should not hire an ex-client as a staff member. It creates potential conflicts of interest between the new staff and his/her supervisors who may have previously been therapist or counselor to this person. It can also create situations where the ex-client has relationships with current clients and this gets messy.
If you do practice hiring ex-clients for staff you should consider having written policy in place that protects the clients, the staff member, and your agency with some concrete policies such as: Require 2-years have passed prior to hiring, require that the position being filled isn’t being supervised by the staff’s ex-counselor or therapist, that the inbound staff member has no access to the charts for anyone they went through treatment with, etc.
Conflicts of interest occur when a treatment professional has interests or relationships that may interfere with his or her ability to perform professional roles.
Dual relationships exist when a treatment professional is in a professional role with a person (e.g., therapist and client) as well as another relationship with that person or someone close to that person.
Almost every licensed or certified person in this profession has a code of ethics that includes a requirement to avoid or carefully minimize the presence of dual relationships.
Crossing those boundaries often lead to blurry ethical behaviors which can get worse over time.
There are many treatment centers out there stating that they specialize in co-occurring disorders, or that they specialize in LGBTQ issues (and other examples), but don’t actually have the clinical staff or programming to support those claims.
To work with co-occurring disorders you would need to have licensed MFT or LCSW personnel on staff working with those issues. To work with LGBTQ clients you need clinical staff who are clinically trained for that and programming that supports that. To work with eating disorders you need medical staff on hand.
SUD Counselors cannot engage in therapy and they aren’t qualified to treat eating disorders.
If you recognize that your client may need a higher level of care, or a lower level of care (based on ASAM criteria and professional clinical observation), the ethical behavior would be to promptly make a skilled and appropriate referral for that client to that needed level of care rather than taking some kind of “I can help this person” stance or attempting to preserve your program census for financial purposes.
Substance use treatment professionals are held by strict privacy standards and there are specific bodies of law that govern privacy for clients (see references below). If you are discussing a client (without express and written client consent) with friends, family members, or peers who are not involved in that client’s treatment, then you are violating that client’s privacy rights.
Oftentimes a treatment center wants to show their success stories as a marketing strategy, and this practice is not something that is automatically unethical, but it certainly can come with pitfalls.
The client who is making the testimonial or volunteering to be part of the “marketing story” must have full agency in the decision and you would want to have very specific consents about how the testimonial/story/photos is/are to be utilized. You should be aware that they may feel obligated to help and they should be fully informed about the public nature of such information.
It’s one thing to have a very solid personal and professional ethic, but it is also important that you make any third-party agencies or services that you do business with aware of your ethical practices as well as insisting that they, too, are practicing the same high standards.
This would include, but is not limited to; call centers who refer calls to you, internet marketing agencies you contract with, and other treatment centers you refer clients to.
Plausible deniability, i.e., I didn’t know, is not an option.
There are times when an employee of a treatment center witnesses unethical practices and they are afraid to say anything for fear that they may lose their job or their standing in the community.
If you find yourself in this situation and do not take a stand for it, then you, by omission, are also participating in the unethical activities.
Unethical practices can only live in the darkness, and it’s up to all of us to do our part to bring them into the light.
Sober living homes are not currently regulated, certified, or licensed in any meaningful way most places in the country. There are some attempts at self-regulation by associations such as The National Alliance for Recovery Residences (NARR) and some states are trying to pass bills that would regulate sober and transitional housing.
Sober livings exist to provide a structured and sober environment that have established rules, sometimes requirements for 12-step attendance, occasional dip-panel (not lab) drug testing, and often chores.
But some sober living homes attempt to go outside of their scope by engaging in activities they are not licensed for such as: medication dispensing or monitoring, billing insurance for UA or other medical testing, providing a treatment program other than on-site 12-step meetings, etc. Let’s be clear: Those practices are unethical if you are not certified or licensed to do so.
Residential treatment facilities get licensing based on the number of residential beds they have. Unless they are a larger facility, this is often limited to six beds. There are instances where residential treatment facilities stack their beds beyond their licensing so that they can bill more. There are even instances where they place residents in hotels or in the homes of staff people to exceed their license count. This is dangerous and it is most certainly and illegal and unethical practice.
Some treatment centers engage in a number of fraudulent billing practices that include:
- Unnecessary treatment, over-utilization of services, or too high a level of care
- Unneeded UA, lab or other diagnostic testing
- Billing for supplements or other unnecessary prescriptions
- Padding bill to cover free sober living bed
- Billing for services not rendered (also double-billing)
- Misrepresenting dates, providers, or locations of service
- Waiving of deductibles, co-insurance, or co-payments
Reference: Association of Certified Fraud Examiners
If you are in-network with a client’s insurance company, the waving of any co-payments, co-insurance, or deductibles would be against your contract with the insurance company and therefore would be a fraudulent billing practice.
If you are out-of-network with a client’s insurance company (i.e.; you’ve no contract with that insurance provider), then any kinds of discounts or waivers of client fee responsibility might be considered as an inducement and you should take great care about how you approach this. Any offering of such fee modifications should have a transparent and defined system of application that takes actual financial hardship (measured) into account. It’s murky waters and a good idea to err on the side of caution.
- Waiving Co-pays and Deductibles
- Can my treatment center waive co-pays and deductibles?
- Legal Compliance: One More Reason to Collect Patient Deductibles and Copays
- Health Care Providers May Waive Patients’ Copayment Obligations, But…
- Re: Co-payment and Deductible Waivers
- The out-of-network co-pay conundrum – To waive or not to waive … And how?
If you are a clinical professional or the owner of a treatment center, it is vital that you not only set out expectations of ethics for your staff, but also that you provide an environment that is a safe space to call out behavior or practices that are unethical. The tree rots from within.
It’s also worth noting that if you are a business person owning a treatment center and you don’t have clinical training, it is vital for you to defer to your clinical management staff when it comes to the ethics of clinical issues. There are times when “whats good for the business” and “whats good for the client” do not match, and the clinical needs of the client must always hold sway.
Here are some good links to articles about creating an ethical environment: