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Can a doctor get state’s blessing to work with 37 addiction centers?

November 23, 2025

It’s a point of pride, major selling point and plain old common sense: Have an actual medical doctor assist licensed addiction treatment centers as they care for patients quitting dangerous drugs and alcohol.

This sort of partnership, verboten in California until 2016, offers “the utmost convenience for our guests,” some facilities crow. “These medical professionals can provide real-time medication adjustment, medically assisted detox, medication assisted treatment ….”

But, for the doctors involved, how many is too many? The vast majority of medical professionals approved to provide “incidental medical services” in Orange and Los Angeles counties work with just one or two different facilities, according to data from the California Department of Health Care Services, which licenses and regulates addiction treatment centers.

One doctor, however, is approved to work with 37 different facilities.

Two other doctors each have the okay to work with 22 different facilities.

Three more are each approved to work with 15.

And the list goes on.

Providing medical care at so many centers would be an unfathomably heavy load, several physicians who work in addiction medicine said. Most couldn’t imagine handling more than one or two themselves.

No cap, no tracking

Despite its role as regulator, DHCS has no cap on the number of facilities a doctor can be approved to work with. The department does not keep track of that information, a spokesperson said.

“DHCS enforces Title 9 of the California Code of Regulations to ensure proper oversight and adequate care, which is the responsibility of the facility and the supervising physician,” a spokesperson said.

In a Public Records Act request, filed in May, we asked DHCS for data on all the doctors approved to provide “incidental medical services” to addiction treatment facilities in California.

That would be an enormous undertaking, we were told, because that information is not kept in any centralized location.

So we narrowed our request to just Orange and Los Angeles counties. Turns out that these two counties — which contain just a third of the state’s population — are home to about half of all California facilities approved to offer “incidental medical services.”

But do these approvals represent facilities that doctors currently work with? One doc with approval at nearly two dozen facilities suspects that DHCS doesn’t update its records when a physician stops working with a center, even though such changes must be reported. We asked the doctor how many of these 22 he currently works with, several times. He did not answer the question.

Why does it matter? Patients’ health is on the line, of course, but there’s also the issue of money. Working with a physician allows facilities to bill for medical care, which can be worth hundreds of dollars — or much more — per patient. A doctor who works with more facilities stands to make more money.

Also, IMS can be provided by telehealth, which might make things easier to fudge. Records released in the course of a lawsuit noted that a doctor had provided IMS without proper clearance, was unfamiliar with detox protocols and insisted he saw patients who said they had never met him.

When DHCS asked that doctor for proof of his medical evaluations for these patients — such as a log of Zoom video calls — the doctor responded this way: “I don’t believe the way I conduct Zoom is set up the way you are looking for … sorry I couldn’t be of more assistance!”

What the heck is IMS?

The key word with “incidental medical services” is “incidental.” That’s because addiction treatment facilities licensed by DHCS are expressly non-medical, despite the many online pitches from rehabs that suggest otherwise.

In the bureaucratic parlance: “‘Incidental Medical Services’ means optional services provided at a facility by a health care practitioner, or staff under the supervision of a health care practitioner, that can address medical issues associated with detoxification, treatment or recovery services,” says the DHCS’s IMS bulletin.

“IMS must be provided at the facility in compliance with the community standard of practice. IMS does not include general primary medical care or medical services required to be performed in a licensed health facility….”

The first of the 10-page health questionnaire

Once approved, “the following IMS must be provided: 1. Obtaining medical histories; 2. Monitoring health status; 3. Testing associated with detoxification from alcohol or drugs; 4. Providing alcoholism or drug abuse recovery or treatment services; 5. Overseeing patient self-administered medications; 6. Treating substance abuse disorders, including detoxification.”

A health care practitioner also must review a new client’s health intake questionnaire no more than 72 hours after admission. This includes serious queries such as, “Have you ever had a heart attack or any problem associated with the heart?” and “Have you ever tested positive for tuberculosis?” as well as questions about diabetes, open wounds, head injuries, seizures, delirium tremens and convulsions.

How does the state go about approving doctors for such tasks? They must complete a form stating, among other things, “I acknowledge incidental medical services does not include the provision of general primary medical care.” The facility they’ll work with also must fill out forms, requesting approval for IMS and detailing staffing data. DHCS also directed us to a FAQ about IMS here.

Load bearing

Most physicians carry a lighter load, by design.

-Of the 124 practitioners in Orange and Los Angeles counties approved to provide IMS, the vast majority — 87 — handle just one or two facilities each.

-Another 29 stick to the single digits, approved to handle between three and nine facilities each.

-Just eight are in the double digits — approved for between 11 to 37 facilities each. Combined, those eight are approved to serve 129 facilities.

What does the job of a medical director at an addiction treatment center entail, exactly?

The American Society of Addiction Medicine’s guidelines say the medical director has the ultimate responsibility for all care. That person should be a physician or an “advanced practice provider” with at least two years of documented experience in addiction treatment, according to the guidelines.

A heroin user holds suboxone, a medication for opioid addiction. (Photo by Spencer Platt/Getty Images)

The medical director also is responsible for developing, approving and regularly reviewing the program’s admission criteria and medical policies, procedures and protocols; directing patient care; ensuring the adequacy of individual treatment plans; ensuring daily medical coverage to meet patient needs; determining the credentials required of other physicians and advanced practice providers who serve the program; monitoring the care delivered by other physicians and advanced practice providers who serve the program; and overseeing the quality of treatment delivered by the program, ASAM’s guidelines suggest.

That is not an inconsequential amount of work. So does that mean being responsible for 37, or 22, or even 10 facilities, is too many?

Dr. Larissa Mooney, director of UCLA’s Addiction Psychiatry Division and professor of clinical psychiatry, said that among her colleagues — including those in private practice — she didn’t know anyone who worked with more than two.

That’s pretty much the personal cap for Dr. Randolph Holmes, medical director for two facilities that provide IMS. In addition to Holmes, there’s another board certified addiction doctor and a nurse practitioner helping cover the two sites.

In this photo illustration, a bottle of the generic prescription pain medication Buprenorphine (Photo illustration by Joe Raedle/Getty Images)

“I only know my own capacity,” Holmes said. “One or two is an ideal. Everybody I work with, most of us do one or two and we’re maxed out.

“I think capacity depends on the doctor and how much oversight you feel comfortable with. It’s hard to pay attention and keep care going if you’re spread thin,” he added.

“I want to double check back and forth with the other doctors…. If they hire a bunch of nurse practitioners, they can maybe do 20 or 30, but I don’t know anyone who does that many. I don’t know how you do 20 or 30.”

Dr. David Kan would agree.

“My recommendation is that you need to have adequate time and capacity to serve patients to the level of medical necessity,” he said. “These patients are often complicated with comorbid SUD, medical issues, detox, etc. Telemedicine can extend your reach but simply signing papers without medical review is grossly insufficient.

“I don’t believe an arbitrary number is the answer,” Kan added.

“It should be in the service delivery itself.”

‘It depends’

A physicians’ IMS load is something the California Society of Addiction Medicine has been debating.

“I’ve given this issue a lot of thought because I have been a medical director at treatment facilities that provided IMS in the past and have served as an expert witness in many legal cases where the standard of care was breached,” said Dr. Mario San Bartolome Jr., a board member at CSAM who also chairs an Addiction Services Quality and Safety Committee, who spoke for himself and not the association.

“We did start to address this at the ‘7 Deadly Sins’ pre-conference workshop at the last CSAM conference. Many of the participants had the same question. However, it’s not a simple answer. In much the same way you would ask a pulmonologist, ‘How many ICUs/hospitals should you have privileges at to serve patients?’ It depends.”

That said, though, San Bartolome’s work in the “medico-legal realm” of addiction treatment has led him to be conservative. He favors depth — highly involved directorship emphasizing quality over quantity — over broad coverage. He wants to closely follow all key points as patients transition from detox to residential to outpatient treatment, as bad things happen most often during transitions.

“I have been a medical director for a hospital-based detox unit with extremely sick patients, a detox attached to residential treatment, a free-standing detox, and an (out patient) detox … All carry different risks. But spreading yourself thin without very specific mitigation strategies is a recipe for disaster,” he said.

It is possible for a physician to review health histories and vital signs and drug screenings by telehealth for multiple facilities, agrees Dr. Alta DeRoo chief medical officer for the esteemed Hazelden Betty Ford Foundation — if that physician has solid support and personal bandwidth.

“One of the ways they can do this is to have order sets, standing orders, algorithms that nurses on site are told to follow,” said DeRoo. ‘If someone comes in with this type of substance use disorder, start them on these meds.’ That’s a way you can have lots of facilities with no doctor on site, and follow up later when it’s convenient.”

This was a common order of operations during the pandemic, but it’s not her favorite way to provide care. “Do I like it? No, I don’t like it,” she said. “There’s a lot of information to be gathered by looking at a patient’s eyes, at their pupils, smelling them, watching their gait, feeling their perspiration, their tremors.

“We may continue treatment with virtual services, but we prefer, or require, for a person to have on-site, in-person services to begin with,” she said. “It’s important to develop rapport, confirm identity and physically assess the person.”

The Hazelden Betty Ford Center in Rancho Mirage is one of California’s exceedingly rare chemical dependency hospitals, subject to much more rigorous oversight than California’s nearly 2,000 licensed or certified addiction treatment facilities.

We’ll be delving into detail on the doctors and their IMS loads in coming months. Is the state regulator doing as much as it could or should to ensure the quality of IMS? We’ll leave you to ponder this last Q&A from DHCS’s “frequently asked questions” page:

“Is there a minimum number of hours of addiction medicine training required?

“No.”

Orange County Register

News Details

Can a doctor get state’s blessing to work with 37 addiction centers?

No cap, no tracking

What the heck is IMS?

Load bearing

‘It depends’

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