Every Claim Failed: Auditor General Finds BHDDH’s Opioid-Clinic Oversight Didn’t Work—and Medicaid Paid $875,696 in Daily Methadone Bills It Should Have Bundled

What happened

On Wednesday, Oct. 7, Rhode Island’s Office of the Auditor General, led by Auditor General David A. Bergantino, released a performance audit of how the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) oversees the state’s opioid treatment programs. These are the licensed methadone clinics that bill Medicaid. The audit was done jointly with the federal HHS Office of Inspector General. It covers Jan. 1, 2023 through Dec. 31, 2024, when five providers billed Medicaid for 274,412 medication-assisted treatment services totaling $25,541,470.

The headline finding is blunt. Auditors pulled a random sample of 100 of those services, and every one of the 100 “failed to meet at least one compliance requirement.” Across 88 federal and state requirements, they counted 1,729 deficiencies. They found 99 instances of noncompliance with medication-assisted treatment requirements, 95 involving the biopsychosocial assessments required at intake or at the five-year mark, 75 involving six-month treatment-plan reviews, 70 involving required counseling, 51 involving annual assessments, 50 involving annual treatment plans, 42 involving annual medical exams and 22 involving drug tests. The report calls this “a systemic lack of compliance.”

The audit puts the cause on the regulator. BHDDH’s licensing unit did audit all five providers every two years. But the report says those biennial audits “were not effectively ensuring provider compliance,” and that BHDDH “did not compile and evaluate provider results in a manner sufficient to determine if its monitoring procedures were effectively ensuring compliance.” Projecting from the sample, auditors estimated that services worth $24,921,184 did not meet federal and state requirements. The report calls that “the lower amount in the range of potentially unallowable costs” estimated by the federal inspector general.

The second finding is about money that plainly shouldn’t have gone out. Rhode Island’s Medicaid State Plan requires methadone treatment to be billed as one bundled claim per patient per week, and the audit says daily billing “is not authorized.” Auditors nonetheless identified and validated 6,347 claims in which Medicaid paid providers for daily methadone visits instead. In many cases, providers sent in five to seven daily claims for the same patient in one week, “causing the State to pay several times more than the established weekly bundled rate.” The result was $875,696 in potential overpayments, of which $656,919 is the federal share. The auditors blamed provider noncompliance and “the absence of adequate system controls within Medicaid systems,” meaning no edits in the managed-care or state encounter-data systems to catch the billing. In the report’s words, “RI Medicaid did not ensure that controls were in place to prevent or detect the improper payments.”

Both agencies’ responses are printed in the report. BHDDH promised unannounced visits, six-month follow-up reviews, provider self-audits at least every six months, standardized templates, mandatory training, a compliance threshold of about 90%, and a quarterly compliance dashboard. It also said it “will maintain its established biennial audit protocol.” The Executive Office of Health and Human Services (EOHHS), which runs Medicaid, said corrective-action plans “that include recoupments are in the process of being reviewed.” It said it is working with its Medicaid-systems contractor, Gainwell Technologies, on guardrails. It also said it is “in the process of confirming with Gainwell that a system correction was implemented in 2024.” Neither agency gave completion dates.