Advocates Urge OIG to Make It Easier for SUD Providers to Offer Contingency Management

Substance use disorder (SUD) treatment stakeholders are asking the Office of the Inspector General (OIG) at the Department of Health and Human Services (HHS) to make it easier for providers to use contingency management to help people overcome addiction. 

Contingency management uses positive reinforcement to motivate certain behaviors. In the case of SUD treatment, that usually means rewarding patients with money or gift cards when they meet certain treatment adherence or abstinence goals. 

The evidence-based, clinically validated method has been recommended by the National Institutes of Health (NIH), the U.S. Surgeon General and the American Society of Addiction Medicine (ASAM).

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However, contingency management still isn’t widely available to SUD patients, largely due to the Federal Anti-Kickback Statute, which prohibits federal health care programs from giving patients gifts or money in an attempt to bring in more reimbursable business.

But more than a dozen organizations are trying to change that. ASAM and 15 other organizations recently wrote a letter asking the OIG to create a new safe harbor provision to the Anti-Kickback Statute to protect the use of payments provided as part of contingency management for SUD treatment. 

“While OIG has offered that evidence-base [contingency management] practices do not necessarily implicate the Federal Anti-Kickback Statute and civil monetary penalties prohibiting beneficiary inducements, the lack of a safe harbor for this effective treatment option leaves providers to request case-by-case advisory opinions regarding their practices – a time-consuming process that impedes [contingency management] availability,” the authors wrote.

The letter was signed by ASAM, the National Association for Behavioral Healthcare (NABH), the American Academy of Addiction Psychiatry (AAAP), and several other well-known advocacy groups.

The organizations stressed that such a safe harbor is important because it would allow more providers to offer contingency management, which is currently one of the only effective treatments shown to help people kick addictions to psychostimulants such as cocaine and methamphetamine. 

“[Contingency management] is among the most effective evidence-based psychosocial treatments for SUD,” the authors of the letter wrote. “With appropriate safeguards in place to prevent fraud, waste, and abuse, it can and should be made available to all patients receiving SUD treatment.”

Between 2012 and 2018, the rate of overdose deaths involving psychostimulants increased by nearly five times. And amid the pandemic, things have only gotten worse, which is why stakeholders want to remove barriers to contingency management.

The authors of the letter proposed several suggestions for how to allow contingency management under the Anti-Kickback Statute while also preventing fraud and abuse. For example, they suggested the safe harbor include validated protocols for incentives; requirements for documentation of treatment plans and medical necessity; standards for success measurement; and rules around the marketing of contingency management, among other recommendations. 

Finally, the authors also encouraged OIG to issue similar guidance for contingency management under the Eliminating Kickbacks in Recovery Act of 2018 (EKRA), which makes it illegal for any health care provider receiving government or private reimbursement to take part in any sort of kickback arrangement in return for referrals.

“Even with the recommended safe harbor for [contingency management] under the [Anti-Kickback Statute], healthcare providers offering [contingency management] in accordance with established clinical guidelines and within the recommended guardrails could still face liability under EKRA. Thus, we urge OIG to issue guidance clarifying the permissibility of [contingency management] or propose a similar safe harbor for [contingency management] under EKRA.

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