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  • Ruth Amos RN JD

Substance Abuse Treatment Fraud- As Dark as it Gets

Earlier this week, I posted a video on LinkedIn with a rather cryptic message to look out for my blog on its topic. There’s good reason- the video touches on a subject most people do not want to discuss. Here’s the video link in case you have not already seen:

NBC Left Field- substance abuse fraud

Back when ACA (the Affordable Care Act, aka “Obamacare”) was enacted, there was a provision included that required health insurers to cover substance abuse treatment- a noble cause to be sure. Unfortunately, there were little to no regulations written that govern facilities claiming to be “treatment centers.”

With the opiod crisis in full swing, these treatment centers have sprung up overnight across the US. No doubt many are reputable; however, lack of regulation has allowed a type of fraud opportunity that is as dark as it gets.

We’re all familiar with the basic insurance fraud scam- billing Medicaid, etc for false claims. That is happening in treatment centers on an unprecedented scale, with duplicate drug screening charges and extended treatment not medically warranted. This blog touches on  much darker realities- residents who are deliberately given, withdrawn and given again illicit drugs to keep them addicted and in need of additional treatment. As if this weren’t bad enough, the cycle of deliberate drug addiction for profit has an even darker side; these persons become ripe for sex trafficking, since they are now totally dependent on the “treatment center” for food, shelter and drugs.

The profit margin on this activity is staggering, and the current ability to catch and prosecute the criminals behind it is frighteningly small. Victims are often moved from one city or state to another to avoid detection- commonly known as the “shuffle.” Most vulnerable are young women whose family ties are weak to non- existent. No one is searching for them.

So what can be done to limit these horrible scenarios? The first reaction is more legislation to regulate these types of facilities, and I certainly advocate steps in that direction. However, increased legislation takes time, and many lives will be lost by then. I propose a more practical approach that can be initiated now and potentially assist law enforcement in gathering much needed data on facilities that may be engaging in illicit activities. The following is an example of a simple checklist that can be built into an EHR and followed by healthcare personnel to screen substance abuse facilities before a patient is transferred from the Emergency Department or inpatient space. You will need to edit and pass through your legal department, of course. Reporting capabilities are also critical to understand how many patients have been moved to which facilities, along with audited tracking of readmission rates and identification of facilities in questionable repute.

If a facility fails the checklist, there may be grounds to report them to law enforcement for further investigation. Also, if a patient is transferred and later readmitted to the hospital for an overdose, etc, the detailed information is in the EHR from last time and the facility may require additional scrutiny. While helping protect the patient, it can also serve to help shield hospitals from liability by showing performance of due diligence:

1.    Does the facility have a valid state license to operate (if the state requires one)?

2.    Has the facility been reported to law enforcement or government agencies for any illicit activity or unsanitary conditions (provide and update local, state and federal agency/law enforcement contact information)?

3.    Who is in charge of the facility (President, Board of Directors, et al)?

4.    Do any of the above have a criminal history? (you’d be surprised)

5.    How long have they been in business?

6.    Have they ever done business under another name or have a dba?

7.    What is the average length of stay, along with shortest to longest stay data? (make them give you the data- if they refuse, that’s a red flag)

8.    How many other facilities do they operate and where are they located?

9.    Have they ever been fined for any type of violations?

10.  What lab(s) do they use for urine drug screening? (this can be important if the lab comes under scrutiny)

The above list contains only a sample of what could be and is merely illustrative. I welcome additional insights into these efforts. We can and must be vigilant to utilize data to help keep these vulnerable patients safe while being strong advocates for legislative reform.


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