By Ryan J. Rusak
It’s an alarming story that doctors, families, law enforcement officers, and insurers say they’ve all heard: A person with opioid use disorder, desperate for help, calls a number from an ad or website. Hope seems to answer, offering a prepaid trip to a treatment center in a sunny climate, along with insurance-paid care.
But all the treatment amounts to is a series of tests designed to bleed insurance coverage, sometimes for tens of thousands of dollars. If the patient relapses or the coverage runs out, he or she is suddenly turned out, far from home and with no medically sound treatment for the underlying problem.
Experts on the nation’s opioid crisis say they know unethical treatment is an issue, but they don’t have a sense of the entire picture – facts and figures that could help policymakers and insurers crack down. A new study funded by Arnold Ventures seeks to change that.
“There's just a lot of room to take advantage of people because [substance use treatment] has been outside of the normal bounds of healthcare quality for as long as it's existed,” said Julie Williams, a public health manager who works on opioid policy for the philanthropy.
Arnold Ventures is funding a two-year study led by researchers at Boston University, who will look for signs of fraud in insurance data. Then, under the direction of a top former federal health-fraud investigator, “mystery shoppers” will contact potentially fraudulent providers to examine their sales pitches.
The goals: Develop a tool that insurers can use to detect fraud and outline the scope of the problem so policymakers can develop regulatory guidelines and procedures for overseeing treatment centers and their affiliates.
The lack of knowledge about the reach of fraudulent treatment has hampered any coordinated effort to tackle it, said Melissa Garrido, the lead researcher on the study.
The project is “the first attempt to really estimate the national scope of opioid use disorder, treatment, fraud, and waste,” said Garrido, a research associate professor at the Boston University School of Public Health and associate director of the Partnered Evidence-Based Policy Resource Center at the Boston VA Healthcare System.
The study fits the philanthropy’s overall mission of ensuring that sound research informs public policy. But there’s an additional motivation – filling a gap on a crucial issue.
“Unethical treatment is an area that just isn't getting the same level of attention from the government” as other problems of the opioid crisis, said Sarah Twardock, a public health manager for Arnold Ventures. “And that's something that we kind of see as a philanthropy sweet spot, stepping in when no other actors for the public good are making sure issues are studied and get attention and are acted upon.”
Access to Care
Public Health Manager Sarah Twardock talks about changing Medicaid policy at the state level to increase access to care for opioid use disorder during a panel discussion at Johns Hopkins University in January.
When Arnold Ventures sought more information about how common unethical treatment is, they turned to Michael Adelberg, a principal at the law firm Faegre Baker Daniels, who helped the philanthropy sketch out a plan to study the issue in partnership with leading researchers.
Adelberg, a former senior auditor and regulator for the U.S. Department of Health and Human Services, said he believes the data will show an issue throughout the nation, not just in places such as Florida or California, where several such scams have already been exposed.
He and other experts have identified a typical pattern. A patient often stays at a recovery house, known colloquially as a “sober home,” many of which have little medical grounding. A clinic runs thousands of dollars' worth of tests, particularly frequent urine screenings, billing the insurance provider along the way.
The scam hurts not just the patient but also the entire system, said Austin Frakt, an associate professor at Boston University and director of the VA system’s policy resource center. He’s working with Garrido on the study.
“These poor people who were looking for some help, they're turned out on the street, and they've gotten no help, and now they're miles away from home,” he said. “It’s bad all around. It’s a waste of health care dollars. It’s bad for the patients.”
The research team will start by plumbing data on insurance coverage for more than 50 million people, including those who have purchased policies in the Affordable Care Act’s marketplaces. That’s important, Garrido said, because such policies tend to offer more coverage for out-of-state providers, a common element of the fraudulent treatments.
As an example, the team will search for unbundled lab tests – billing insurance for individual medical tests rather than a one-time, comprehensive scan. Researchers will look for geographic clusters of referrals and other signs that a “patient broker” was involved in connecting treatment centers with patients.
That information will help refine an algorithm, which researchers will ask private insurers to run on their own data, Garrido said, to identify potentially fraudulent operators.
That’s when the “mystery shoppers” go to work.
Adelberg’s firm will hire a company to develop a script and train callers to ask about treatment, seeking “a much fuller picture of bad conduct, misinformation, high-pressure sales tactics.”
Garrido said the data should provide an estimate of how much fraudulent care is costing the U.S. health system. And researchers would make the algorithm publicly available so insurers, and even federal and state officials, can use it to detect fraud.
“The long-term hope is that this informs and motivates introduction of new bills to combat treatment fraud and maybe informs some regulatory action to tighten the oversight of treatment providers and recovery houses,” she said.
Matthew Rubin, a health care adviser at Faegre Baker Daniels who is the firm’s expert on the opioid epidemic, said better knowledge of the deficiencies of treatment could shift the conversation on opioid use disorder.
The study aims to wrap up by the end of 2020, and a fuller understanding could lead to standards for state and federal officials to oversee addiction treatment. What’s needed, Rubin said, is a “baseline for individuals that would want to operate a recovery residence or treatment center and ensuring that they are credentialed and they maintain a certain level of ethics and integrity.”
These poor people who were looking for some help, they're turned out on the street, and they've gotten no help, and now they're miles away from home.Austin Frakt associate professor at Boston University