RI Nonprofit Cited for Potential Medicaid Fraud - Immediate Corrective Action Ordered
GoLocalProv News Team
RI Nonprofit Cited for Potential Medicaid Fraud - Immediate Corrective Action Ordered
The Warwick-based nonprofit provides mental health and substance use services. It was established in 1976 and employs more than 200.
GoLocal secured a copy of the EOHHS letter on Monday.
GET THE LATEST BREAKING NEWS HERE -- SIGN UP FOR GOLOCAL FREE DAILY EBLASTThrive’s CEO, Dawn Allen, refused to respond to questions, and Board Chair Jennifer Wheelehon did not respond to email.
A PR company sent a statement on behalf of Thrive that said in part, “Thrive is deeply concerned that a confidential communication from EOHHS was made public. Thrive denies the allegations in the letter and will be meeting with the agency in short order and will present materials to the agency that will address the audit’s allegations, as is the standard procedure. No legal or administrative action has been taken against Thrive relating to this matter. The allegations within the letter are preliminary in nature and are not actionable until the organization and agency meet to determine their legitimacy.”
Potentially Putting Children at Risk
EOHHS cites a number of concerns with the nonprofit following a review.
The letter to Thrive’s Allen states, “[Thrive’s] failure to retain the Designated Collaborating Organization (DCO) responsible for providing Mobile Response and Stabilization Services (MRSS) constitutes a material change in the terms and conditions of Thrive’s certification as a Certified Community Behavioral Health Clinic (CCBHC). This change directly compromises a core safety requirement of the CCBHC model and places the health and safety of children in Thrive’s designated catchment area at risk. Thrive’s unilateral decision to discontinue the use of the qualified MRSS provider – without timely or adequate notice to the State – jeopardizes Thrive’s continued certification as a CCBHC and necessitates immediate corrective action."
The EOHHS letter further stated, “This failure to maintain and report changes to MRSS capacity constitutes a material change in the terms and conditions of Thrive’s certification as a CCBHC and places the health and safety of children in your designated catchment area at risk. Thrive’s unilateral action without State notification jeopardizes Thrive’s continued certification as a CCBHC.”
"Thrive must coordinate care across the spectrum of health services to meet the needs of the children served. Unfortunately, it has come to Medicaid’s attention that Thrive is not meeting these access and coordination of care requirements contained in the Certification standards. We understand that Thrive has failed to manage and coordinate care for children attributed to Thrive. Thrive under the terms of the Medicaid Provider Agreement and the CCBHC Certification Standards is responsible for the coordination of care for all children attributed to Thrive,” states the letter.
EOHHS says failure to rectify the situation could lead to significant ramifications.
“Therefore, to avoid sanctions Medicaid is instructing Thrive to work with the designated DCO or provider to ensure continuity of care, accessibility and the health and safety of children attributed to the Thrive’s designated catchment area. Please note that Thrive’s failure to provide such coordination of care services could result in findings of patient abandonment exposing Thrive to sanctions up to and including exclusion from the Medicaid Program.”
Allegations of Fraud and "Shadow Billing"
“In addition to Certification Standards compliance issues, Medicaid has received tips concerning Thrive, that include allegations of fraud, waste and abuse prompting an audit focused on the frequency and adequacy of shadow billing, as well as monthly Prospective Payment System (PPS) billing," writes EOHSS in its letter.
"Medicaid’s Office of Program Integrity conducted audits of Thrive’s claims and found that Thrive has repeatedly and continuously violated Section III Billing Requirements of the Billing Manual,” said EOHHS.
Audit
Further, the letter cites, “At the time of the Office of Program Integrity’s (OPI) audit, Thrive had approximately 2155 Medicaid members. Between October 1, 2024, and August 31, 2025, Thrive Behavioral Health, Inc. billed Neighborhood Health Plan of Rhode Island (NHPRI) $5,583,495.82 accounting for thirty-seven percent (37%) of Thrive Behavioral Health, Inc. members. Thrive Behavioral Health, Inc. also billed Rhode Island Medicaid through Fee for Service (FFS) claims in the amount of $7,877,784.00, thirty-five percent (35%) of their members. Thrive Behavioral Health, Inc. billed Tufts Health Plan of Rhode Island (THP) $417,444.00 accounting for four percent (4%) of Thrive Behavioral Health, Inc. members and United Health Care (UHC) $3,902,299.07 accounting for twenty-four percent (24%) of their members. The combined total amount of Medicaid claims filed by Thrive Behavioral Health, Inc. for reimbursement during this above audit referenced period is $17,781,022.89.”
Overbilling Questions
“All PPS claims paid without a billable event or triggering event can be subject to recoupment. This could result in a recoupment of $7,906.00 of claims that were billed to Neighborhood Health Plan (NHPRI), $1,444.00 billed to Tufts Health Plan (THP), $1,535.00 billed to United Health Care (UHC), and $743,864.00 billed directly to Rhode Island Medicaid. The total amount that could be recouped for PPS claims paid without any triggering event claims is $754,749.00,” adds EOHHS in its letter.
“Since October 1, 2024, until August 31, 2025, Thrive has billed a total of 8,945 claims for Clubhouse Services using CPT code H2031. The total amount paid for the 8,945 claims is $563,226.65. This amount reflects additional payment to Thrive apart from the monthly PPS and is not included with the shadow billing process. Reimbursement for clubhouse services is already factored into the PPS payments through the reported clubhouse activities included in the cost report. This could result in a recoupment of $252,572.67 of claims that were billed to Neighborhood Health Plan (NHPRI), $78,838.44 billed to United Health Care (UHC), and $231,855.54 billed directly to Rhode Island Medicaid. Therefore, the separate payments made for CPT code H2031 for clubhouse services constitute duplicative payments. Currently, there is no state plan authority to provide Clubhouse Services. Going forward, any clubhouse services must be shadow billed using CPT code H2023,” stated EOHHS.
Thrive was also ordered to take numerous corrective actions and “Thrive must provide the State by close of business January 9, 2026, with assurances that the provision of MRSS services will default to the approved MRSS DCO provider.”
The letter to Allen was signed by Kristin Pono Sousa, the Medicaid Program Director for the Rhode Island Executive Office of Health and Human Services