$6 Billion in Fraud Found by OIG
Telemedicine, Sober Homes, and Opioid Prescriptions
6 Billion in Opioid Takedown, 345 Defendants Charged, across 51 federal districts, including 100 doctors, nurses, and other medical professionals. We’ll focus on the less-known area of fraud which is the referrals to sober homes that are already receiving federal grants which is how they were able to tie in the connected network.
Fraud and Financial Impact
In September 2020, in the Eastern District of Texas, 345 defendants were charged across 51 federal districts, for healthcare fraud involving Telemedicine and Opioids. Telemedicine charges totalled more than $4.5 Billion, while $845 was related to substance abuse rehabilitation homes, and $806 million was connected to substance abuse facilities and Opioid prescriptions.
While many are jumping at the cause of this Fraud being COVID, hold the presses, as most of the network and fraud was pre-COVID. As you dig deeper you’ll find they exploited many different loopholes to initially get paid claims for DME, lab and diagnostics, Opioid prescriptions and kickback referrals and consultations, as well as a laundry list of other less frequent charges including unnecessary treatments and referrals to Sober Homes. This was a calculated program of defrauding Medicare and Commercial plans to seize profits.
What are Sober Homes?
Sober Homes was the language used by many Government Agencies about this Fraud Case. A “Sober Home” is a controlled environment where individuals after completing or while completing an in-house rehabilitation for drug and/or alcohol abuse go to live a drug and alcohol-free life for some time until they can care for themselves in the world. The most famous sober home is Hazelden Betty Ford. Facilities are licensed, peer-run, supervised and integrated with transitional services to better reintegrate into society.
Halfway House are Different than Sober Homes
Halfway Houses are best known as the living spaces for those exiting jail or prison. It gives them time to address their past transgressions, and drug and alcohol addictions, obtain employment, and prepare to become productive members of society. So while Sober Homes are usually referred from inpatient recovery centers, Halfway Houses are mostly court-ordered.
Why Fraudsters Exploit Sober Homes
Someone being placed in a Halfway House is checked in on by parole and/or probation officers and there are strict requirements. Sober Homes are peer-run and subject to tempting offers of kickbacks.
The Fraud comes into play as the Treatment Center supplies a referral to the Sober Home establishment which is receiving federal grants through the Center for Substance Abuse Prevention, Center for Substance Abuse Treatment, and the Center for Mental Health Services. Getting federal grants does take time and you have to complete forms and registration to be properly evaluated. However, once you're in the program that's where the initial intent can turn into fraudulent cases like this.
Government Grants
Someone being placed in a Halfway House is checked in on by parole and/or probation officers and there are strict requirements. Sober Homes are peer-run and subject to tempting offers of kickbacks.
Our History and Credibility in Reporting this Information:
For over 30 years, PCG Software Inc. has been a leader in AI-powered medical coding solutions, helping Health Plans, MSOs, IPAs, TPAs, and Health Systems save millions annually by reducing costs, fraud, waste, abuse, and improving claims and compliance department efficiencies. Our innovative software solutions include Virtual Examiner® for Payers, VEWS™ for Payers and Billing Software integrations, and iVECoder® for clinics.
