Rhode Island Audit Faults Opioid Treatment Records and Billing

Rhode Island's Office of the Auditor General released a performance audit Wednesday finding that every one of 100 sampled opioid treatment services billed to Medicaid fell short of at least one state or federal requirement, and identifying $875,696 in potential overpayments tied to how the state's clinics billed for daily methadone.

The audit, signed by Auditor General David A. Bergantino and conducted with the Boston office of the U.S. Department of Health and Human Services Office of Inspector General, covered claims from January 1, 2023, through December 31, 2024. It concluded that oversight by the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, known as BHDDH, did not ensure providers complied, and that a billing gap sat open inside the Executive Office of Health and Human Services (EOHHS), which runs the state's Medicaid program.

What the auditors actually reviewed

The performance audit took in all five opioid treatment programs that submitted Rhode Island Medicaid claims during the two-year window, at 14 locations. Out of a population of 274,412 medication-assisted treatment services worth $25,541,470, the federal inspector general's office drew a random statistical sample of 100 services at a 90 percent confidence level. Auditors visited the providers, read their policies and procedures, and pulled the clinical records behind the sampled claims, testing 88 federal and state requirements across 11 areas. They counted 1,729 deficiencies.

The distribution matters more than the total. Auditors found 99 instances of noncompliance with medication-assisted treatment requirements and 95 involving intake or five-year biopsychosocial assessments, the broad evaluations of a patient's medical, psychological and social circumstances that establish medical necessity. Six-month treatment plan reviews accounted for 75 findings and required counseling for 70. Annual biopsychosocial reviews produced 51, annual treatment plans 50, annual medical examinations 42 and toxicology screens 22. Progress notes and medical services with care coordination were the exceptions, both at 95 percent compliance.

The report is direct about why incomplete records are not a clerical problem. "Without complete, updated and aligned treatment plans, providers cannot reliably monitor progress, identify relapse risks or adjust care," it states, adding that the gaps weaken medication-assisted treatment and increase the likelihood of treatment disengagement or adverse outcomes.

The methadone billing finding

The dollar figure auditors could verify on the merits is narrower — and more mechanical — than the estimate of deficient services.

Rhode Island's Medicaid plan pays for opioid treatment under a weekly bundled rate. Auditors identified and validated 6,347 claims in which providers billed daily methadone encounters under the code H0020 instead, in many cases submitting five to seven daily claims for the same patient in a single week. Those claims total $875,696 in potential overpayments, of which $656,919 is the federal share. A Medicaid managed-care code list effective July 1, 2023 describes H0020 as one unit per week.

Separately, the report projects from its sample that services totaling $24,921,184 did not meet all requirements — the low end of the federal inspector general's range of potentially unallowable costs. That number is a statistical estimate rather than a recovery order, and the auditors do not present it as money the state has already been told to return.

How the two agencies answered

BHDDH is the primary licensing and regulatory authority for opioid treatment programs and audits providers every two years. It told auditors it would keep that cycle while adding follow-up reviews and unannounced visits. The department proposed requiring providers to self-audit at least every six months, standardizing documentation tools, training clinical staff and supervisors, and running a compliance dashboard updated at least quarterly.

EOHHS said its corrective action plans would include recoupments. It accepted the recommendation to review adjudicated and pending claims filed under H0020, calculate the total overpayment, seek repayment where appropriate and return the federal share, and to build a control into the Medicaid plan that prevents daily claims from being paid at all.

Both responses are commitments rather than deadlines. The audit notes that the state has not set dates for the fixes, which leaves the timing of any recoupment — and of any change in how clinics document care — up to the two agencies.

Why the paperwork is the treatment record

Opioid treatment programs are the only settings in most states permitted to dispense methadone, and they operate under a stack of federal and state rules that assume the clinical record is accurate. Assessments establish that a patient needs the medication. Treatment plans and their reviews create the paper trail justifying continued dosing. Drug testing documents whether the plan is working.

When those records are thin, the enforcement question and the clinical question collapse into each other. Because medication-assisted treatment is now the default expectation in state Medicaid programs, documentation quality is a payment issue as much as a care issue, and Rhode Island's five providers continue to bill while the review plays out. What the audit has changed for now is the record itself: an independent office concluded that the paperwork the state relies on to police its opioid treatment system fell short at every provider it checked.