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Payers are ramping up addiction treatment audits

As the government looks to expand coverage, providers are seeing more intense documentation requests

Editor's note: This article has been updated to correct the spelling of attorney Kelly Hagemann's name. 

Health payers are intensifying investigations into addiction treatment services with more comprehensive records requests, according to one healthcare attorney.

Kelly Hagemann, an attorney with Michelman & Robinson LLP, writes on the firm's blog that payers are sending more records requests for substance-abuse treatment services. Beyond medical and billing records, she says several major payers are "aggressively" investigating claims by requesting information about patient residency as well as facility licenses, and state and country certifications. Some large payers have frozen payments or requested recoupments of $1 million or more.

Hagemann underscores requests made by Health Net--a managed care organization that delivers government-sponsored plans--that specifically ask providers whether they have made or received payments to induce patient referrals.

"In other words, providers are being asked to attest that they are not breaking the law," Hagemann writes. "Health Net's requests are not accompanied by any evidence or allegations against the specific provider, but rather appear to be sent out on a large scale to numerous recipients."

Addiction treatment has received much more attention as of late because of growing concerns surrounding the opioid addiction crisis across the country. In some cases, payers are investing in more interventions, including hiring social workers or placing limitations on the amount of pain medication a patient can receive with an initial prescription. Meanwhile, the federal government is considering increasing coverage for addiction treatment to allow Medicaid managed care beneficiaries to receive 15 days of inpatient rehab each month.

However, some addiction treatment providers have come under fire for potentially fraudulent practices. In April, the Department of Justice expanded its probe into Universal Health Services, which specializes in behavioral health and addiction treatment, and a New York Times investigation last year exposed a potential scam involving "three quarter houses" in New York City.

To learn more:
- read the Michelman & Robinson LLP post

Related Articles:
Health insurers tackling the opioid epidemic
New York City's unregulated 'three-quarter houses' ripe with Medicaid fraud
DOJ expands criminal fraud investigation to Universal Health Services headquarters
Feds announce intentions to provide funding for addiction treatment