Protect Your Organization and Provider Network from Insurance Fraud and Abuse in the Substance Use Disorder (SUD) Treatment Market

Drug and Alcohol Abuse, The Addiction Crisis – SAMHSA

Substance use/misuse and addiction represent a significant and substantial public health challenge. Data from the 2014 National Survey on Drug Use and Health (NSDUH) reveal that an estimated 27.0 million Americans aged 12 or older were currently illicit drug users (defined as using any of the following in the past 30 days: Marijuana/hashish, cocaine/crack, heroin, hallucinogens, inhalants, or non-medical use of prescription-type psychotherapeutics such as pain relievers, tranquilizers, stimulants, and sedatives) and 16.3 million were heavy drinkers (defined as drinking five or more drinks on the same occasion on five or more days in the past 30 days). Approximately 6.5 million people aged 12 and older reported currently using psychotherapeutics non-medically.

According to the 2014 NSDUH, 21.5 million Americans aged 12 or older had a substance use disorder in the past year. Among them, 14.4 million Americans had dependence or abuse of alcohol but not illicit drugs, while another 4.5 million had dependence or abuse of illicit drugs but not alcohol, and 2.6 million had dependence or abuse of both alcohol and illicit drugs. People with alcohol or illicit drug dependence or abuse were defined in the 2014 NSDUH as meeting the diagnostic criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV).

The Affordable Care Act and new mental health parity protections are expanding mental health and substance abuse treatment benefits to 60 million Americans. Despite this historic expansion of health insurance coverage and other advances, too many Americans are not benefiting from treatment services. Based on the 2014 NSDUH data, although 21.5 million people aged 12 or older met the DSM-IV criteria for alcohol or illicit drug dependence or abuse, only an estimated 2.3 million received substance use treatment in the past year.

Drug poisoning (overdose) was responsible for about 47,000 deaths in the U.S. in 2014 (now the latest year for which national data are available). Furthermore, substance misuse (to include excessive alcohol use) and related disorders contribute to injury and chronic illness, lost productivity, family disruptions, and increased transmission of sexually and injection-related infectious diseases; are associated with higher rates of domestic violence and child abuse; and prevent many individuals from realizing their full potential.

Family Response to Drug Abuse and the Holidays

If a loved one shows up, ruining family events and holidays under the influence of alcohol or drugs, what should I do?

  1. Distinguish the love you have for the person from the frustration you feel about their behavior. Talk openly about the two with your loved one and your family.
  2. Talk openly with your family and the person with the substance use problem about the problem. Don’t keep secrets.
  3. “Invite them to get help”- pushing/ controlling usually makes things worse. Take care of yourself and your family by setting limits.
  4. Set limits with your loved one and let them know that you will drive them to a treatment center to get help.
  5. Set limits with your loved one and let them know that you will drive them back home if they show up or become drunken or drugged.
  6. Set limits with your loved one and tell them that family time is off-limits for drunken or drugged behavior.
  7. Make it clear to your loved one and your family that they are “sick”, not “bad”.
  8. Communicate “stern love”: you care so much that you want to help them get well, rather than supporting them to destroy themselves.

How can I prepare my family for another holiday with someone’s alcohol or drug abuse problem?

  1. Before holidays and family events, communicate openly with the family and the loved one with the alcohol or drug problem and set a plan.
  2. Decide upon responses to and limit setting about drunk or drugged behavior and follow-though!
  3. Let the person with the alcohol or drug use problem know that the family loves them and only wants to help them get better.
  4. Communicate to the family and loved one the meaning of “enabling”: supporting continued alcohol or drug abuse by avoiding, ignoring, or enabling drunk or drugged behavior.
  5. Offer to meet with the substance abusing loved one before the event or holiday to discuss how their problem affects you, and to help find them treatment for the problem.
  6. Call a professional or treatment program before you meet with the loved one so as to prepare for an opportunity to help them get better.

What do I do if my loved one with the alcohol or drug use problem denies their problem or gets angry?

  1. Communicate “stern love”: you care so much that you want to help them get well, rather than continue to destroy themselves.
  2. Use the “broken record” technique”: repeat what you are saying if it isn’t being heard or considered.
  3. Express your caring, compassionate feelings before expressing your frustration.
  4. Recall and discuss incidents where drunk or drugged behavior ruined family events or holidays. Describe your past excuses for their behavior.
  5. Attempt to get the help of a professional or a friend who has experience with recovery.
  6. Step away from the conversation if you find yourself becoming angry or controlling.

What do I do if a family member or members don’t want to deal with or talk about the problem?

  1. Let them know that secrets and silence enables alcohol and drug abuse to grow into deeper, more dangerous conditions.
  2. Remind them of past occasions where family events or holidays were ruined by drunk or drugged behavior.
  3. Discuss possible consequences of your loved one’s continued alcohol or drug abuse.
  4. Discuss possible outcomes of talking openly with your loved one about their problem.
  5. Suggest reading material related to alcohol and drug abuse/ addiction.
  6. Set a plan.

Dark Web Marketplace Increases Availability, Acceptability of Drugs: Expert

dark-web-featuredThe popularity of the “Dark Web” for purchasing illegal drugs is especially worrisome because it is increasing the availability and acceptability of drugs, according to an addiction psychiatry expert.

“After talking with people who use the Dark Web, I became very concerned that many of them have lost the appreciation that this is drug dealing, not just e-commerce,” says Karen Miotto, MD, Director of UCLA’s Addiction Psychiatry Service, who has studied the Dark Web, also known as the Deep Web or the Hidden Web. “Buying or selling heroin balloons in the park is clearly understood as an illegal activity; buying or selling drugs online may be construed as e-commerce without full appreciation that it is also illegal.”

The Dark Web refers to illegal online marketplaces that can be accessed by downloading the anonymous browser called Tor, and purchasing the digital currently bitcoin. In addition to illegal drugs, these websites sell passports, pornography and weapons.

The first and most well-known Dark Web site was Silk Road, which was shut down by the federal government in 2013.

The ease with which people can buy large quantities of drugs is creating a system with mid-level drug dealers, said Dr. Miotto, who discussed the Dark Web at the recent California Society of Addiction Medicine annual meeting.

She found people who use the Dark Web by asking students and colleagues for contacts, as well as through the website Reddit.

“We have a new drug distribution system,” Dr. Miotto said. “People can get drugs sent to them in a FedEx box right to their door with a sense of anonymity and confidentiality. There’s a sense of intrigue and excitement about getting drugs this way.”

Earlier this year, a study by Carnegie Mellon University researchers found illegal websites have sales that average $300,000 to $500,000 a day. The study found marijuana accounted for about one-quarter of sales, followed by Ecstasy and stimulants. These websites also sell significant amounts of psychedelic drugs, opioids and other prescription medications.

Dr. Miotto found that hallucinogenic compounds advertised as research chemicals are popular on Dark Web sites. “Some people believe they are performing a service by experimenting with these drugs and going online and writing about their experience,” she said.

When Silk Road was seized in October 2013, it had 13,000 drug listings. In June, the creator of Silk Road, Ross Ulbricht, was sentenced to life in prison. The government said over Silk Road’s three years in business, more than 1.5 million transactions were conducted on the site.

A number of new Dark Web sites have emerged since Silk Road was seized, including Open Bazaar, Silk Road 3.0 and Angora. “People write in testimonials about the drugs they purchase on these sites, just as you do on Amazon,” Dr. Miotto notes.

She said parents’ and physicians’ ignorance of the Dark Web makes it easier for young people to participate in the online drug marketplace. “Young people don’t always appreciate the risk they are taking in engaging in these activities,” she said. Parents can check to see if a Tor browser has been downloaded on their teen’s computer. Check packages that come to the house, and don’t allow your teen to have their own Post Office box. If your teen asks about Bitcoin, find out what he knows about it and why he’s interested in it.

“I worry about young people with disposable income and access to credit cards,” Dr. Miotto said. “Some of the most tragic cases I’ve seen are high school kids, or even younger, with a lot of discretionary income.”

What does the research say about Intensive Outpatient and Day

Treatment working as well or better than residential treatment for alcohol and drug abuse and addiction:

“Treatment on an outpatient basis allows a more valid assessment of environmental, cognitive and emotional antecedents of drinking episodes and drinking urges on the part of the patient, and allows the patient to test new coping strategies while still within a supportive counseling relationship. These conditions would be expected to foster greater generalization of learning in treatment to the patient’s natural environment” (Annis, 1986, p. 183).


What are some of the different features of outpatient treatment which create better outcomes than in residential treatment setting?

  • Therapeutic and supportive relationships are not disrupted in outpatient treatment.
  • Therapeutic rapport with therapists, psychiatrists, prior sobriety supports and physicians are maintained.
  • Strengths and assets at work, home, recreation can be built upon during the course of outpatient treatment.


Isn’t learning new skills and avoiding drug and alcohol use at home more difficult than in a clean and supervised environment?

  • Rather than learning in a nice clean laboratory, apply the new skills directly into your life now. Outpatient treatment provides a much greater “take-home” advantage.


The benefits of getting sober at home actually enable newly sober people to

  • Practice new skills immediately in real-life situations;
  • Apply new discoveries, ideas and behavioral changes- practice improves retention;
  • As clients and families learn more effective coping, communication and relationship skills, they can “practice” these skills both in treatment and at home
  • Clients and families receive support and validation from each other while expanding their lasting sober supports in outpatient settings. Relationships can be maintained and won’t be disrupted at discharge as in residential treatment.


While you participate in an intensive outpatient or day treatment program for alcohol and drug abuse and addiction, what sober resources are found at home different from those in a residential program?

  • Outpatient treatment mobilizes available supports (family, therapist, psychiatrist, family doctor, and/or mutual support organizations) rather than creating temporary and artificial supports that will be removed once a residential experience ends.
  • Indigenous recovery supports are identified and activated during the course of outpatient treatment.
  • The transition from active outpatient treatment into social support and recovery maintenance is much less abrupt than with residential treatment. Social support gains are generalized into real life.
  • Clinical changes, recovery supportive resources, therapeutic and professional relationships are likely to be maintained.


Addiction creates casualties and long-lasting problems. How is this wreckage handled differently in an outpatient setting treating substance use disorders?

  • People coming to terms with an addiction often face mounting financial, vocational and domestic problems- “wreckage”.
  • Treatment should not add to those mounting bills, unnecessary absence from work and home.
  • Rehab should instead help move you into the solution- toward resolving the “wreckage” of your addiction.


Why is residential treatment so widely recognized as the way to get sober?

  • Residential treatment will produce better profit/ development margins for the business owner/ provider of care if critical business volumes can be achieved.
  • The higher operating costs, administrative time, and professional oversight of residential components draw decision-makers to focus on their residential treatment at the expense of their less complex and less lucrative outpatient services.
  • It is clear to the margin-oriented administrator that short-term financial gains will be best made from a residential model if only the beds can be filled.


Substance Use Disorder or Addiction

The words we use to describe alcoholism and drug addiction evolve with social, political and scientific change. Alcoholism and drug addiction have been the subject of huge social scorn and condemnation. People who cannot control their alcohol consumption and others who use other addictive drugs bring tragedy upon not only themselves, but also to their loved ones and society as a whole.

Eighty years ago as people began to recover for the first time, their stories became better understood. Medicine began to advocate for greater research as the biological causes of this “disease” were discovered. Prejudice, judgement and shame slowly subsided as solutions began to be uncovered; hope replaced disgrace.

Terms change as greater information is uncovered. Professionals from medicine, psychology, sociology, criminology, theology, etc. bring unique perspectives to the far reaching impacts of alcohol and drug abuse. The words we now describe “Substance Use Disorder” attempts to diminish stigma while capturing the essential characteristics of the disorder which includes a continuum of intensity and severity.

What was once a hopeless condition viewed as sinful, weak, criminal, deviant, crazy is now viewed as a chronic, relapsing medical disease which has far reaching impact. Alcoholism and drug addiction became chemical abuse or dependent. Substance abuse and dependency is now considered substance abuse disorder. This new concept describes a continuum of symptoms from mild to severe, allowing each individual unique characteristics and consequences.

Recovery from Alcoholism and Drug Addiction- What is Recovery?

Ideas and words like “recovery”, “sobriety” and “clean and sober” make sense to people who have crossed the bridge from addiction to recovery, but people still suffering from the effects of the disease may not share that understanding. When a person trapped by their own need to drink or use chemicals arrives at the greater need to stop, they may be ready for recovery. Recovery starts with the realization that continuing to drink or use worsens existing problems and is a problem itself. At this point, the drink or drug creates negative consequences and a greater need to drink or use drugs next time.

Addiction (including alcoholism) is characterized by many signs and symptoms. One of the more telling signs is when someone encounters negative consequences from their substance use yet continues despite such consequences. Addiction (including alcoholism) is a psychiatric disorder and medical disease- it is chronic, progressive and relapsing with biological, emotional, cognitive, social and spiritual effects. (“Crazy” is when you take the same action but expect different results.)

Recovery starts with avoiding the first drink or drug… abstaining from addictive substances one day at a time. Once the chemical and its effects are physically absent and slowly become psychologically distanced, recovery can then become a process of learning, understanding, becoming increasingly aware, practicing new skills, and monitoring personal ideas, feelings and behaviors. The recovering person discovers an openness to learn and understand new ideas, and to practice new behaviors and skills. Change becomes possible in recovery.

New friends and acquaintances who are understand and support sobriety are gained- a new sober support network is introduced. People learn that the old secrets and isolation worsen feelings of loneliness and hopelessness. Expressing uncomfortable feelings and openly describing the sensation of craving decreases their intensity and builds behavioral practices of honesty and authenticity.

People who have encountered the same help strengthen each other’s sobriety through fellowship and service to each other. Giving back and becoming helpful to others strengthens recovery practices and builds self-esteem. Rather than the drunk or drugged fantasizing about fame and fortune, the recovering person gains self-esteem though estimable action.

In-Network HMO, EPO and PPO Covered Addiction Rehab

Working people and their families are often covered by affordable health care coverage offered through managed healthcare plans such as HMO’s (heath management organizations), EPO’s (exclusive provider organizations) and PPO’s (preferred provider organizations). The Affordable Care Act has resulted in healthcare exchanges such as “Covered California” where people can purchase affordable healthcare insurance which is priced according to their income.

HMO, EPO, and PPO insurance plans usually relegate behavioral healthcare coverage and management to behavioral healthcare departments or organizations. The reason that services provided by alcohol and drug rehabilitation and treatment centers are managed separately by behavioral health departments is that diagnoses, prognoses and progress cannot be measured through conventional biological markers or measurement tools. A specialist in behavioral health is required to determine the level and type of care needed for complex diseases such as alcoholism and drug addiction now referred to as “substance use disorders”.

Costs and personal restrictions are better contained when a professional who is financially independent from the provider oversees care and monitors costs. Treatment can become exorbitantly expensive when there exists no such oversight. For some people with wealth, rehab can be combined with an extended luxury vacation. Not everyone can or should afford luxury or lengthy treatment.

When you seek a provider contracted with your insurance healthcare plan, the coverage is much better and the services are closely monitored for quality and cost. Ethical business practices can also be enforced such as providing you and your family about the best estimate of cost before a contract is signed.

Providers who are “out-of-network” will often state that they accept insurance. Before signing contracts, take the following steps to protect yourself:

  • Ask the out of network provider if they will give you a written estimate of what the out-of-pocket cost will be after the insurance stops authorizing payment for treatment
  • Ask if they will provide you an itemized bill which they send to your insurance company, including the charges for urinalysis
  • Ask if the provider gets approved for all services rendered and ask how long the insurance company is likely to approve payment
  • Ask if they bill you the balance after the insurance company ceases to cover treatment and how much that total is likely to run.

To protect you and your family from unethical business practices or to avoid unnecessary costs and services, ask you insurance representative or therapist for their expert opinion.

If holiday or vacation drunkenness and drugging gets out of control, is this a sign of a real problem? What are the signs of alcoholism and drug addiction?

Imagine time off from work or other responsibilities such as a holiday or vacation. Is a drink or some form of drug automatically connected with relaxation? Do you anticipate what you will drink, smoke or use? Can you have a good time without getting high using some type of drink, substance or chemical? Reliance on chemically induced happiness might be replacing the natural good times.

When relief from pain or discomfort requires non-prescribed chemicals or if you simply have to have a drink, bump, snort, puff to set yourself into a better mood, you may have come to rely too heavily on those substances.

The DSM 5 (Diagnostic and Statistical Manual, 5th Edition- American Psychiatric Association) proposes the following as common signs of a substance use disorder, commonly called “addiction”. If you present three (3), the chances are high for having a substance use disorder/ addiction:

  • Failure to meet responsibilities/ obligations due to use
  • Risk and danger created when using
  • Continued use despite negative social and financial consequences
  • A need for more quantity of the substance to achieve the same high or state of relief
  • Symptoms of withdrawal (hangovers, lows, come-downs) when using stops or has been interrupted
  • Inability to control or decrease use
  • Taking a higher quantity than was originally intended
  • More time is spent getting and preparing to use the drink or drug
  • Recreational activities and events are substituted with drinking or using
  • Continued use despite adverse psychological or medical effects
  • Craving, hunger or a strong desire for the effect of the chemical.

Are recreational, leisure events with family or friends being sacrificed for opportunities to drink or get high? Does having a good time require drinking or using (partying)?

Recovery allows the addict to return to or pursue new healthy and natural highs. Being with friends and family or attending a sporting event or entertainment can become once again enjoyable. Simple pleasures slowly return. The color returns to a once gray world.

If you or a loved one miss the times where a vacation or holiday meant a good time to relax and enjoy friends and/or family, recovery is possible. There are many ways to start. Call a sober friend. Go to a 12-step meeting or mutual support group.  Carefully select or get a referral to call a treatment center. Schedule an appointment with an addiction specialist or therapist.

Life can be fun again. You can again enjoy time off without the drama created by the over use of alcohol or other drugs.

Drug and Alcohol Rehab while living at home: Intensive Outpatient and Day Treatment

Many people think that “drug and alcohol rehab” means moving into a treatment center, staying in their bed, eating their food and having a roommate. Moving away from your normal living circumstances might at times seem necessary to make the changes necessary to obtain sobriety or engage in a program of recovery. Research has not found that this level of care is necessary or more effective in most cases. (1)

Residential or inpatient care is usually necessary when medical detox is needed, or if environmental containment and supervision is required due to behavioral or psychiatric disorders. If a person is living with or adjacent to others with similar problems, it is important that another living environment is found. Getting sober around using others is unlikely.

The benefit of undergoing treatment in your normal environment is that you will immediately apply your new discoveries and changes into real world conditions. Rather than hoping that you can take home what is obtained in a protective living environment under the supervision and twenty-four hour care of professionals, at home you will learn how to apply the new skills directly into your life. You will also be able to bring in the early sobriety stresses, problems and “wreckage” to the program and to the group for real-world help.

People coming to terms with an addiction often face mounting financial, vocational and domestic problems- “wreckage”. Treatment should not add to those mounting bills, unnecessary absence from work and home. Rehab should instead help move you into the solution- toward resolving the “wreckage” of your addiction.

Most people undergoing treatment today do not have the resources to pay for the higher costs related to a residential level of care. Before committing, it is important to obtain a clear view of the costs involved with residential care and avoid relying upon general statement about the center billing the insurance and putting the rest on a payment plan. The rest could turn out to be the majority of the costs of a very expensive treatment encounter. Make sure that you are aware of what you are committing yourself and family.

  • (1)”Subjects benefited equally from outpatient and residential aftercare, regardless of the severity of their drug/alcohol problem.” Differential effectiveness of residential versus outpatient aftercare for parolees from prison-based therapeutic community treatment programs. William M Burdon1, Jeff Dang2, Michael L Prendergast1, Nena P Messina1 and David Farabee 1, *Corresponding author: William M Burdon, 1University of California, Los Angeles, Integrated Substance Abuse Program, Substance Abuse Treatment, Prevention, and Policy 2007, 2:16 doi:10.1186/1747-597X-2-16 
  • “Previous reviews have concluded that there was no evidence for the superiority of inpatient over outpatient treatment of alcohol abuse, although particular types of patients might be more effectively treated in inpatient settings. We consider the implications of our findings for future research, especially the need to examine the conceptual rationales put forward by proponents of inpatient and outpatient treatment, i.e. mediators and moderators of setting effects.” The effectiveness of inpatient and outpatient treatment for alcohol abuse: the need to focus on mediators and moderators of setting effects, JOHN W. FINNEY, ANNETTE C. HAHN, RUDOLF H. MOOS Article first published online: 24 JAN 2006 DOI: 10.1046/j.1360-0443.1996.911217733.x Addiction Volume 91, Issue 12, pages 1773–1796, December 1996 
  • “Greater service intensity and satisfaction were positively related to either treatment completion or longer treatment retention, which in turn was related to favorable treatment outcomes. Patients with greater problem severity received more services and were more likely to be satisfied with treatment. These patterns were similar for patients regardless of whether they were treated in outpatient drug-free programs or residential programs. The positive association between … greater levels of service intensity, satisfaction, and either treatment completion or retention-and treatment outcome strongly suggests that improvements in these key elements of the treatment process will improve treatment outcomes.” Relationship between drug treatment services, retention, and outcomes. Hser YI, Evans E, Huang D, Anglin DM. Neuropsychiatric Institute, University of California-Los Angeles, 1640 South Sepulveda Boulevard, Los Angeles, CA 90025, USA. 
  • National studies indicate significant reductions in recidivism following outpatient treatment Pre-treatment Post-treatment, Drug Abuse Reporting Program (DARP), National Treatment Improvement Evaluation Study (NTIES), Treatment Outcome Prospective Study (TOPS) 
  • Outpatient treatment of probationers leads to fewer arrests at 12 and 24-month follow-up (Lattimore et al., 2005) vs. untreated probationers 
  • High-risk probationers receiving outpatient treatment experience 10-20% reductions in recidivism (Petersilia & Turner, 1990, 1993) 
  • Reductions in probationer recidivism durable for 72 months after outpatient treatment (Krebs et al., 2009) 
  • Outpatient treatment more effective than residential treatment for drug-involved probationers (Krebs et al., 2009) and during reentry (Burdon et al., 2004) 
  • Greater benefits for the cost for outpatient treatment in non-offender samples (CALDATA, French et al., 2000, 2002) 
  • Aftercare services among drug-involved offenders can significantly reduce substance use and re-arrest (Butzin et al., 2006) 
  • Outpatient aftercare services can reduce likelihood of re-incarceration by 63% (Burdon et al., 2004) 
  • Aftercare services provide $4.4 – $9 return for every dollar invested (Roman & Chafing, 2006) 
  • “…(M)ore severe patients experienced better alcohol and drug outcomes following in-patient/residential treatment versus out-patient treatment; on the other hand, patients with lower baseline ASI drug severity had better drug outcomes following out-patient treatment than in-patient treatment. Treatment setting was unrelated to alcohol outcomes in patients with less severe ASI alcohol scores. Conclusions Results provide some support to the matching hypothesis that for patients who have higher levels of substance use severity at intake, treatment in in-patient/residential treatment settings is associated with better outcomes than out-patient treatment.” Day Hospital and Residential Addiction Treatment: Randomized and Nonrandomized Managed Care Clients; Jane Witbrodt, Jason Bond, and Lee Ann Kaskutas Alcohol Research Group, Constance Weisner, University of California, San Francisco, Gary Jaeger; Kaiser Foundation Hospital, David Pating, Kaiser San Francisco Medical Center, Charles Moore Sacramento Kaiser Permanente, Journal of Consulting and Clinical Psychology Copyright 2007 by the American Psychological Association, 2007, Vol. 75, No. 6, 947–95 
  • “Compared to those receiving no treatment, those receiving nonresidential treatment took longer to fail or recidivate. However, those receiving residential treatment did not differ from those who received no treatment in time to failure. In the treatment-only model, nonresidential treatment participants took longer to fail than their matched residential treatment counterparts.” The impact of residential and nonresidential drug treatment on recidivism among drug-involved probationers: A survival analysis. Krebs, C. P., Strom, K. J., Koetse, W. H., & Lattimore, P. K. (2009). Crime & Delinquency, 55, 442-471.