A benchmarking approach for characterizing providers’ patterns of treating patients with substance use disorder

Abstract

It is difficult to identify fraud, waste, and abuse (FWA) in substance use disorder (SUD) treatment. Insurers use outlier detection models to detect SUD-related FWA but these models require credible benchmarks based on cross-payer claims data. To our knowledge, these benchmarks have not been established for SUD-related services frequently cited in fraud cases — drug screening, psychotherapy, and partial hospitalization. We used de-identified and aggregated data from FAIR Health’s national database of commercial claims, including ACA marketplace plans, from 2014 to 2018 to establish regional benchmarks. We provide additional benchmarks for providers in specialties that most frequently submit claims for patients with SUD. These benchmarks can either be used to determine if a provider’s frequency of claims per-patient-per-month is unusual, potentially signaling FWA, or within a common range for the region or specialty. Our findings can be used to improve detection of FWA – a critical step towards improving the quality of treatment.