Recovery Network of Programs: The Second Claim for Bundled Drug Monitoring
The Recovery Network of Programs laboratory settlement required the treatment provider to pay $354,367 to resolve allegations of duplicate Medicaid payments for urine drug testing. The government alleged that Recovery Network of Programs routinely sent patients’ tests to an outside laboratory even though its weekly methadone payment already covered drug testing and monitoring. According to the government, Medicaid paid the clinic through the treatment bundle, then paid the laboratory for the same work. Connecticut had already audited the arrangement and warned the provider.
The Department of Justice announced the civil settlement on July 23, 2020. Recovery Network of Programs provides substance abuse and mental health services in Fairfield County, Connecticut, and contracted with the state’s Department of Social Services to treat Medicaid patients. The settlement covered conduct from March 1 through October 17, 2017.
The Weekly Methadone Payment Already Included Monitoring
Connecticut Medicaid paid methadone clinics a weekly rate for each patient receiving methadone treatment. That payment bought a package of services. As the Department of Justice described the state’s regulations, the package included an intake evaluation, an initial physical examination, on-site drug abuse testing and monitoring, and individual, group and family counseling.
The testing component matters because a clinic’s payment could cover laboratory work without appearing as a separate drug-test charge. The weekly claim carried the monitoring inside it. Looking only for two identical laboratory claims would miss the arrangement the government described.
In the Recovery Network of Programs case, the government alleged that the clinic routinely referred patients’ urine tests to an independent laboratory. According to that allegation, the laboratory performed the testing and billed Medicaid while the clinic received its weekly bundled payment. The alleged duplication sat across the two businesses: the clinic’s treatment payment and the outside laboratory’s testing payment.
Sending the specimen elsewhere did not remove the monitoring from the package Medicaid had bought. The state’s audit protocol addressed exactly that situation by reducing the clinic’s payment when Medicaid also paid a laboratory for testing within the specified period.
That is the practical question for someone inside a treatment program: when the laboratory billed Medicaid, what happened to the clinic’s bundled payment? The government’s allegation was that taxpayers paid for the included service twice.
Connecticut Explained the Rule, Then Audited the Provider
Connecticut gave Recovery Network of Programs both statewide guidance and a warning about its own billing before the conduct covered by the settlement. The Department of Justice’s account of the state guidance and audit traces the progression from a statewide payment rule to a warning about this provider’s own arrangement.
The Regulation and Provider Bulletin
Connecticut’s 2013 regulations made clear that the weekly methadone rate included on-site drug abuse testing and monitoring. On September 3, 2014, Medicaid sent a Provider Bulletin to all methadone clinics reminding them that the weekly payment included that work.
The Audit Protocol Specified the Payment Reduction
On February 1, 2015, the Department of Social Services published an Audit Protocol for methadone clinics. It said that when an audit found Medicaid had paid another laboratory for drug testing within a week of the date it paid a clinic for methadone treatment, Medicaid would reduce the clinic’s payment by the cost of the laboratory service.
Matching the laboratory claim to the clinic’s treatment payment showed whether Medicaid had also paid for that work inside the bundle.
Recovery Network of Programs Received Its Own Warning
The department audited Recovery Network of Programs and found that both the clinic and an independent laboratory billed Medicaid for drug testing performed by the laboratory, contrary to the weekly-rate regulation. In January 2016, it issued an Audit Report warning the provider that continued noncompliance would lead to payment disallowances in future audits.
The state had already put the problem in writing for this provider. The government’s allegation was that the referrals kept coming anyway.
What an Insider Can See in the Payment Records
The strongest connection in this case is between the weekly treatment payment, the outside laboratory’s claim and the clinic’s response to the audit. Each answers a concrete question. What monitoring had Medicaid already paid for? What did the laboratory bill for the same patient’s treatment period? What changed after the provider received the state’s findings?
Those are the connections our whistleblower experts examine with someone who knows the billing arrangement. A person familiar with outside referrals may understand why the tests kept going to the laboratory. Someone handling Medicaid payments may know how the weekly reimbursement and laboratory charges were treated. Someone involved in the audit response may know what the provider was told and how it acted afterward. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.
You Know How the Outside Testing Was Billed
If you saw a clinic keep its bundled payment while an outside laboratory billed for included monitoring, speak to one of our whistleblower experts about how the outside testing was billed. We work with you to build your strongest health care fraud whistleblower case from the payments and decisions you know, bring in healthcare fraud whistleblower lawyers experienced in laboratory billing, and stand beside you throughout the case.
