Question on prescribing controlled substances in California

djmatte, ADN, MSN, RN, NP · Jan 12, 2021

Not California related, but the laws there seem similar to Michigan. Schedule 2 here can’t have refills (though that maybe more geared toward e-scribing as I rate to never give paper scripts). But we can make our own calls in how we distribute scripts. For scheduled like adderall I require to see those patients quarterly. They call the office monthly for the refill and come in after two calls. Other providers prewrite and date range their scripts for the upcoming months so they don’t have to do it every month. Most of my opiate patients I do require monthly check ins though. However the long term ones who have never had a uds issue I am experimenting with giving longer scripts periods.

paperwork is always touchy, though most disability/Fmla paperwork is a flat $25 fee. I hate this paperwork in general because more often than not they require an md signature and I’m the one stuck doing all of the leg work.

DizzyJ DHSc PA-C · Jan 12, 2021

14 hours ago, FullGlass said:

Hello,

I am currently in mental health. It has always been my understanding that we can prescribe refills for Schedule IV medications in California, such as hypnotics and benzos. Schedule II, which includes Adderall, requires a monthly appointment, as refills are not allowed.

My employer, whom I suspect is only trying to make more money, is saying that state law prohibits Schedule II refills. I tried to research online, and did not find any indication that this is true. This practice also tries to push labs (has their own on-site lab and it is a mental health outpatient practice), including tests of questionable efficacy like Genesite, and charges $100 for filling out any paperwork such as disability requests, including just a note saying the patient had a medical appointment! Most of our patients are poor, lower middle class, or middle class. Given that insurance copays are typically in the $65 to $75 range, these charges are a burden on many of my patients.

Thank you in advance for your insights.

This sounds very familiar to me. . . like I have lived this very same practice. If you don't mind me asking...where do you work? I'm in Ohio now, but spent some time in outpatient psych in Sacramento.

FullGlass, BSN, MSN, NP · Jan 12, 2021

1 hour ago, DizzyJ DHSc PA-C said:

This sounds very familiar to me. . . like I have lived this very same practice. If you don't mind me asking...where do you work? I'm in Ohio now, but spent some time in outpatient psych in Sacramento.

Employer is in Sacramento

DizzyJ DHSc PA-C · Jan 12, 2021

14 minutes ago, FullGlass said:

Employer is in Sacramento

If it is the same place....I worked there for 1 1/2 years when we had just one office....I have many stories.

In regard to refill on schedule II....it was a practice policy that we must see monthly and not a state law.

FullGlass, BSN, MSN, NP · Jan 12, 2021

1 hour ago, DizzyJ DHSc PA-C said:

If it is the same place....I worked there for 1 1/2 years when we had just one office....I have many stories.

In regard to refill on schedule II....it was a practice policy that we must see monthly and not a state law.

Thank you for the clarification

myoglobin, ASN, BSN, MSN · Jan 13, 2021

I thought that the Stark Act prohibited sending labs to a facility where any of the MD's (and one would presume NP's) had an interest? Also, I don't charge for paperwork. I think as long as you send separate electronic orders for each month that you can do three months of schedule II medications. Also, I would argue that making people come in more than absolutely necessary is less than optimal during Covid.

FullGlass, BSN, MSN, NP · Jan 13, 2021

55 minutes ago, myoglobin said:

I thought that the Stark Act prohibited sending labs to a facility where any of the MD's (and one would presume NP's) had an interest? Also, I don't charge for paperwork. I think as long as you send separate electronic orders for each month that you can do three months of schedule II medications. Also, I would argue that making people come in more than absolutely necessary is less than optimal during Covid.

I'm not sure how the Stark Act works here. This is a private practice owned by one MD. Since we are doing telehealth, COVID is not an issue. Actually, I started doing simple letters myself. Some of these letters are literally just 2 sentences!

djmatte, ADN, MSN, RN, NP · Jan 13, 2021

3 hours ago, myoglobin said:

I thought that the Stark Act prohibited sending labs to a facility where any of the MD's (and one would presume NP's) had an interest? Also, I don't charge for paperwork. I think as long as you send separate electronic orders for each month that you can do three months of schedule II medications. Also, I would argue that making people come in more than absolutely necessary is less than optimal during Covid.

That’s an interesting law and the first I’ve ever read in depth about it. Strange part is with our group, we have dedicated holistic medicine, pain management, and they are looking to add other specialties to handle more things under one roof. My question is where does that differ from hospital systems that own primary care offices? Many of those use labs and specialists dedicated to that health system first before referring out. At quick glance, it appears to be individual physician owned situations and may not extend to broader organizations or incorporated entities.

verene, MSN · Jan 13, 2021

In regards to schedule II it's not just a California thing. Every script is technically a "new" script as no refills. That being said, you don't have to see the patient to fill each new script, so long as you see them at least 1x every 6 months you are fine (at least with more stable patients, with less stable I'd recommend seeing them more frequently). You can write multiple scripts with a "fill after" date if you want to accommodate sending a patient with more than one fill at a time, and from patient perspective it will act sort of like having refills (up to 3 months at a time).

Also is your site pushing labs, or are they actually adhering to recommended best practice for labs? (Many places test FAR too infrequently for best practice when it comes to psych meds). They *can* recommend their own site lab (particularly as this may be convenient for patients to one-stop-shop) but need to allow patients to obtain labs elsewhere if they so choose and provide alternate locations if requested.

Charging a fee for disability paperwork and the like is also fairly common practice in mental health field as this is often VERY time intensive work.

DizzyJ DHSc PA-C · Jan 13, 2021

41 minutes ago, verene said:

In regards to schedule II it's not just a California thing. Every script is technically a "new" script as no refills. That being said, you don't have to see the patient to fill each new script, so long as you see them at least 1x every 6 months you are fine (at least with more stable patients, with less stable I'd recommend seeing them more frequently). You can write multiple scripts with a "fill after" date if you want to accommodate sending a patient with more than one fill at a time, and from patient perspective it will act sort of like having refills (up to 3 months at a time).

Also is your site pushing labs, or are they actually adhering to recommended best practice for labs? (Many places test FAR too infrequently for best practice when it comes to psych meds). They *can* recommend their own site lab (particularly as this may be convenient for patients to one-stop-shop) but need to allow patients to obtain labs elsewhere if they so choose and provide alternate locations if requested.

Charging a fee for disability paperwork and the like is also fairly common practice in mental health field as this is often VERY time intensive work.

The scripts are e-prescribed and I don't believe you can send them ahead of time like that. What I ended up doing was having patients email be directly asking for a refill for ADHD meds and I would give them an off month from coming into the office. If they had called the office directly, they would be told they must come in.

In regard to labs, they did not adhere to best practice for labs. They wanted to order unnecessary labs.

For the paperwork they would charge $100 and only give up to 6 weeks (if I recall correctly) for disability. I started filling out the paperwork myself and printing off my own letters because I felt bad for the patients.

myoglobin, ASN, BSN, MSN · Jan 13, 2021

1 minute ago, DizzyJ DHSc PA-C said:

The scripts are e-prescribed and I don't believe you can send them ahead of time like that. What I ended up doing was having patients email be directly asking for a refill for ADHD meds and I would give them an off month from coming into the office. If they had called the office directly, they would be told they must come in.

In regard to labs, they did not adhere to best practice for labs. They wanted to order unnecessary labs.

For the paperwork they would charge $100 and only give up to 6 weeks (if I recall correctly) for disability. I started filling out the paperwork myself and printing off my own letters because I felt bad for the patients.

With the E script I use MD Toolbox although my company uses Advanced MD (which I cannot figure out for medication ordering). Anyways, I send three electronic scripts for 30 days, each dated at the appropriate interval. This is also the way it was done by the psychiatrist I trained under, or he would do paper sometimes. I am only doing labs on drugs like Lithium above 300mg or when their symptoms suggest an issue (in which case I refer them to their PCP) since many of my clients in Washington haven’t even left the house since last March or April due to covid issues.