A rehab clinic in Montana wants to incentivize people with rewards. Then there was a Medicaid fraud investigation.

A rehab clinic in Montana that plans to offer people with substance use disorders $1,966.50 in the form of gift cards and vouchers to follow their treatment program is raising questions. about the use of financial incentives with patients.

The war for the effective but largely unchecked tool is raging in the town of Kalispell, northwest Montana, where a local government grant is funding rewards for those who stick with the method. treatment provided by the Oxytocin outpatient clinic.

Such incentives have gained momentum among individual health clinics and states in recent years. As of 2021, California, Washington, and Wisconsin have started incentive-based programs. Some private clinics offer their own rewards, such as gift cards to customers for successfully passing a drug test.

In Montana, where Republican Governor Greg Gianforte has prioritized expanding behavioral health care, a state pilot program awards addicts to drug addiction. Oxytocin’s program, while funded by a government grant, is separate from the pilot program.

The allowable value of awards available to beneficiaries of federal health programs, such as Medicaid, is a legal gray area, so totals vary from one program to the next. follow.

The federal government has no rules limiting the size of financial awards or detailing best practices, it said. Richard RawsonProfessor emeritus in the Department of Psychiatric and Behavioral Biology at UCLA.

Rawson, who has been researching such incentives for about 20 years, said: “People don’t know where to find this approach, so states and providers will create it themselves as they go. perform.

In June, Montana’s Flathead County awarded the Kalispell clinic, Oxytocin, a $500,000 grant funded from state alcohol tax revenues. Of that amount, $300,000 is set aside to incentivize people to participate in the treatment, as suggested by the clinic. It proposes that over a 20-week course of treatment, participants could earn up to $1,966.50 in the form of gift cards or vouchers.

In the Oxytocin program, a client has multiple opportunities each week to be encouraged by passing urine tests and participating in treatment. The dollar amount increased with successive successes.

The county selected Oxytocin from among four registered clinics that fund drug use treatment. By November, at least one complaint had been filed with state agencies accusing Oxytocin of committing Medicaid fraud by paying their customers – most of whom are Medicaid recipients – high rewards. so to join the treatment.

Oxytocin clinical director Pamela Liccardi declined a request for an interview but said in an email that the business did nothing wrong. “There is a reason the community is behind us and not because we do scams,” she wrote.

Research shows that encourage motivationknown as prophylactic administration, can reduce the number of days a person uses illicit stimulants, such as methamphetamine, and may promote abstinence from other substances, such as opiates, by reinforcing the behavior healthy behavior with prizes, privileges or cash.

“We know people are dying from methamphetamine,” he said Michael McDonnell, a professor of behavioral and community health at Washington State University who has helped states create incentive programs. “Preventive management is the only evidence-based intervention for methamphetamine use disorder. It was the only intervention proven to have a consistent impact.”

But clinicians are wary of violating federal law of 1972 law against fruit that prohibits giving something of value to a federal beneficiary, such as a Medicaid recipient, to get them to choose a particular provider.

There are “safe harbors” to protect certain programs that are unlikely to lead to corruption. But a February legal advice from the U.S. Department of Health and Human Services’ Office of Inspector General says those exceptions do not include incentives aimed at beneficiaries. Federal officials have long been concerned that those kinds of offers could lead to fraud and abuse.

The advisory opinion says: “Programs that involve remunerating beneficiaries can distort health care decision-making, which can lead to overuse of levels, increasing costs, targeting specific providers or providers, or inappropriate medical options”.

The inspector general’s office said whether programs that provide incentives to beneficiaries of federal health programs violate the law against fruition will be decided on a case-by-case basis. The advisory opinion said among the factors was the value of the incentives that did not set a specific standard.

Rawson and other researchers say most vendors consider a total of $75 per customer a year to be safe, based on a 2016 statement from the inspector general’s office about cheap gift to beneficiaries.

However, Rawson said research indicates that amount may be too low to work well as an incentive. Another annual limit that plans face is $600 per customer, the threshold for reporting taxable income to the IRS. Exceeding that amount could cause the beneficiary to exceed the Medicaid income limit, which could result in a loss of coverage.

Last year, Montana officials began a pilot program that expanded substance use disorder treatments and included incentives.

Tammera Nauts, of the Montana Primary Care Association, said the state was careful to avoid giving any red marks to the federal government in the rules the state laid out for the state program. For example, participating clinics cannot award patients for treatment that is covered by the federal government, such as therapy sessions. The state pilot site incentives also cannot exceed a total of $315 per beneficiary per year — the maximum Montana is allowed through the Medicare & Medicaid Services Waiver Center.

Vendors can offer their own rewards program without going through the state, and Nauts said Oxytocin is not one of the pilot sites tied to Montana’s program.

KHN has received a copy of the complaint against Oxytocin. In addition to the Medicaid fraud allegation, it also alleges that Oxytocin has several providers that provide services outside their area of ​​expertise or are unlicensed. The document KHN received did not contain the name of the person who filed the complaint and state officials declined to provide details.

Complaints were filed with the state Department of Public Health and Human Services and the Department of Justice. Health department spokesman Jon Ebelt said it was too early to comment on the case before the review process was complete. Justice Department spokeswoman Emilee Cantrell said the agency’s Medicaid fraud unit is working with the health department but said she could not provide details because the active complaint is considered informational information. confidential criminal justice information.