"It would be very intrusive to the program and to the consumers, because you'd have to explain to the consumers why they're being interviewed," he said. "It could end up creating problems in the therapeutic relationship."

Hepburn said his agency may have waited too long to monitor and limit BBH billings. "There were probably things we should have been more aggressive about and could have been doing a better job on."

Hepburn also pointed to "a number of instances where we were getting inaccurate information" from BBH.

In submitting bills to the state, BBH reported vastly different patient diagnoses than it had while seeking state authorization to treat them, Hepburn said. BBH attributed the differences to clerical mistakes, he said, and insisted that the authorization data was accurate.

In 2007, the state received an anonymous tip that BBH might be billing for services it was not providing. That sparked a 2008 audit by the state health department's inspector general, which examined a sampling of 14,417 paid claims that added up to $1.5 million. The audit found that 10 percent of the claims had errors, including billing for therapy sessions that the patient did not attend.

BBH was ordered to repay $129,000. When a lawyer for BBH failed to appear at a hearing, an administrative law judge entered a default order allowing the state to hold back the sum from reimbursements.

Getting a handle on addiction

To Fingerhood, the addictions specialist at Bayview, a flawed psychiatric diagnosis carries significant consequences. Patients sometimes blame a relapse on a mental disorder that he doesn't think exists, using it as a crutch that keeps them from getting a handle on their addiction.

A former BBH patient named Otis Braswell, 44, said his psychiatric diagnosis became part of his identity. "Once someone tells you something like that, you grab onto it — damn, I'm depressed. You kind of buy into it, you be lying to yourself."

Dr. Michael Hayes of Maryland General Hospital says he has seen dozens of BBH patients who relapsed. While he expressed concerns about how frequently its doctors medicate patients, the addiction specialist said BBH helps fill a gap in a city without enough drug treatment: It's known for taking in and finding a bed for people who have flunked treatment and found the door shut at other programs.

"I wouldn't want to work there," Hayes said. "But I'm glad they're there. Baltimore needs every good or bad treatment program it can find. We have such a huge amount of problems that we can't do without anybody. Any treatment given to an addict is better than their getting it on the corners, honest to God."

But John Belcher, a professor at the University of Maryland's School of Social Work, said there are downsides to "pushing the diagnosis" in any treatment environment. "You may be overtreating the patient, overmedicating the patient, making the patient think they have something they don't really have," he said.

"We may be diverting money from people with serious mental problems to people who don't," Belcher said. "There are some people with serious mental health problems that don't get enough services."

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