Labs, doctors scrutinized over lucrative drug tests for pain-pill abuse
Doctors frequently order patients to take urine drug tests to safeguard against prescription pain-pill abuse.
But federal investigators and Medicare say these routine tests — designed to ensure patients properly use opioid drugs — have led to questionable billing practices by some for-profit labs, doctors, and addiction-treatment centers.
Millennium Health, the nation’s largest lab and one that has conducted widespread testing in Arizona, agreed to pay $256 million to the federal government in October to settle claims that it conducted unnecessary testing.
The U.S. Department of Justice is cracking down on private labs that investigators say offer incentives to doctors to frequently refer patients for lucrative testing. And Medicare, citing the potential for billing abuses, is overhauling its billing codes and payment rates used for drug tests.
Consumers who have been hit with large bills for routine tests say that the cost can quickly become unaffordable.
Phoenix resident Eric Smith visited a local pain clinic in June for treatment of pain from a degenerative disc in his back. The doctor approved a 30-day prescription for Percocet but also required Smith to submit a urine sample each month he sought a refill.
Weeks later, Smith received an itemized bill for a urine test that listed five separate charges for a total charge of $660. He decided monthly tests and other fees such as co-payments and prescription-drug charges would quickly become too expensive.
“This is something I’m dealing with long term,” Smith said. “For those of us with real pain who have to pay for these tests because of the few who abuse (prescription painkillers), it does not seem fair.”
Some tests can be even more expensive. A 75-year-old Fountain Hills man visited the same practice, Arizona Pain Specialists, which has seven clinics in Arizona. He had a urine test that checked for 10 substances, including illegal drugs such as methamphetamine, cocaine and phencyclidine, more commonly known as angel dust. The man was billed separately for each substance for a total bill of $1,048. His insurance plan paid $412.
Doctors who prescribe pain pills frequently say they must order screening tests to comply with medical guidelines.
Arizona Medical Board guidelines encourage doctors to conduct regular urine drug tests on patients who take prescription pain pills. The screens are designed to make sure patients take the prescribed drugs, don’t resell the drugs and don’t mix prescriptions with illegal street drugs. Frequent testing also is a hallmark of addiction-treatment centers, which also have been scrutinized by federal investigators and private insurers.
The medical board has suspended or revoked licenses of doctors who it determined prescribed opioids without proper oversight.
That oversight, according to the medical board’s guidelines, should include “regular toxicologic testing for drugs of abuse.” The guidelines don’t specify which drugs of abuse doctors should test, or how often tests should occur.
Too much testing a concern
Labs and clinics in Arizona and other states use sophisticated tests that measure multiple substances and charge for each individual substance tested, providing more revenue than basic screening tests. Too much testing has long been a concern of Medicare due to potential overbilling, a Centers for Medicare and Medicaid Services spokesman said.
That’s one reason Medicare, the federal health program for the disabled and those 65 and older, is overhauling the way it pays for these tests. Beginning in January 2016, labs and doctors must limit Medicare charges to two categories of billing codes. And in January 2017, Medicare will change payment rates for drug testing.
A Medicare official said the changes aim to remove the incentive for too much testing that has little or no medical benefit.
Medicare wants to reduce the frequent use of confirmation tests by labs that charge for follow-up tests when initial tests show no sign of an illegal substance. Medicare says that some confirmation tests are not medically necessary and inflate charges for taxpayers who support Medicare.
Private health insurers also are scrutinizing and changing payment policies for urine screens ordered or performed by pain doctors, addiction-treatment centers and labs.
“The lab industry has done a lot of over-testing,” said Jennifer Bolen, a former assistant U.S. Attorney in Knoxville, Tenn., who consults on proper opioid screening. “Some of it was encouraged by a lack of sound boundaries (through guidelines). Some of it was pure greed.”
Doctors say they follow guidelines
Doctors who treat patients for chronic pain say they must adhere to state and federal guidelines on how to safely prescribe pain pills. They say they also must keep patients safe from the ravages of pain-pill addiction.
Overdose deaths from opioid prescriptions surged fourfold nationally from 1999 through 2010. Arizona had the fifth-highest opioid prescription rates in the nation in 2010 and was sixth highest in drug overdose deaths.
Arizona has since made small strides in reducing the death rate from drug overdoses. A total of 1,211 Arizonans died from drug overdoses in 2014, a slight drop from 2013. Thirteen states had a higher overdose rate than Arizona in 2014, according to the federal Centers for Disease Control and Prevention.
The CDC recently drafted guidelines that recommended urine testing for pain patients. Arizona doctors who treat chronic-pain patients say state and federal guidelines are instructive.
“Right now, urine testing is really not an option. It is (a) standard of care,” said Patrick Hogan, an anesthesiologist who runs a Glendale pain clinic. “If you are failing to test and you have a patient who has a complication, there is a high likelihood that you would face some disciplinary action from regulatory agencies.”
Doctors who frequently order drug tests for patients will need to navigate Medicare’s new billing requirements.
Medicare billing records show that Hogan ordered the most urine drug screens of any Arizona doctor in 2013. He billed Medicare for 1,943 tests on 368 patients — an average of 5.3 drug screens per patient that year, Medicare records show.
Hogan said that he does not know of any guidelines that limit how often a doctor should order a drug test for a patient. Some larger doctor groups may have their own testing frequency requirements. Hogan said he does not want limits on how often doctors can test.
“How often do you test somebody? I don’t know that there are clear guidelines that exist for something like that,” Hogan said. “I would hate to see something that would usurp provider judgment on that.”
Lisa Sparks, an addiction-medicine doctor and medical director of the Arizona Pain Institute in Glendale, said she decides how often each patient should be tested based on their circumstances. However, Sparks believes routine testing makes “patients realize they can’t cheat the system very easily” by misusing or selling their prescribed drugs.
She often orders panels that tests for multiple substances for patients who are on pain medications, but those tests vary based on the patient. For example, she said she does not test patients for the illegal street drug angel dust because it’s so rarely found in the community.
“We try to avoid overbilling and (limit panels) to do the tests that really need to be done,” said Sparks, who billed Medicare for 741 drug screens on 232 patient in 2013, Medicare records show.
Doctors in other states have been more prolific in billing for these tests. For example, one Connecticut doctor charged Medicare for an average of 198 tests per patient in 2013, Medicare billing records show.
Labs face closer scrutiny
Labs that market tests in Arizona and elsewhere have been subject to enforcement actions and legal settlements.
Millennium Health, a San Diego-based laboratory, in October agreed to pay the federal government $256 million to settle claims that it billed Medicare for improper testing.
The U.S. Department of Justice said that Millennium billed Medicare and Medicaid for unnecessary urine and genetic tests over a seven-year period through May 2015. The company gave doctors free testing cups in exchange for patient referrals, resulting in unnecessary and lucrative testing, federal investigators said.
Millennium Health, previously known as Millennium Laboratory, was the subject of multiple civil lawsuits — including one in Arizona — that alleged billing improprieties. One Arizona-based regional sales manager alleged that sales representatives routinely offered medical practices free urine-testing cups to encourage doctors to order tests.
The lawsuit filed in U.S. District Court in Arizona alleged Millennium gave gifts such as Starbucks gift cards to doctors offices “to both retain existing business and assist in generating additional business.” At the time of the 2012 lawsuit, Millennium denied offering such inducements. The case was dismissed in April with no award to the sales manager.
Millennium officials said the company decided to settle the Justice Department’s multiyear investigation. The company filed for Chapter 11 bankruptcy in November.
“While Millennium may debate some of the merits of the DOJ’s allegations, we respect the government’s role in health care oversight and enforcement,” Millennium CEO Brock Hardaway said in a statement about the settlement. “At the end of the day, it was time to bring closure to an investigation that began nearly four years ago.”
Millennium isn’t the only lab that has caught the attention of investigators and health insurers.
In July, Cigna exited the Affordable Care Act individual marketplace in Florida for 2016 due to an “exponential increase in fraudulent and abusive care delivery practices” among substance-abuse clinics and labs, a Cigna spokesman said.
Cigna also sued Sky Toxicology and two related labs and alleged a “lucrative and improper patient-referral kickback scheme” that connected health clinics with out-of-network labs that resulted in $20 million in excess payments.
The lawsuit alleged that the labs sought doctors and drug-treatment centers that performed enough drug tests to meet a minimum number of referrals to the labs each month. If the doctors and treatment centers met a quota, the suit alleged, they would receive dividend payments based on the lab’s profits, the lawsuit alleged.
Sky Toxicology has denied the allegations, filed a motion to dismiss the lawsuit and is now engaged in settlement talks with Cigna, court filings show.
Richey Wyatt, general counsel for Sky Toxicology, said the lab has decided to wind down operations by the end of this year. He said the decision the shut the lab was due to a “changed landscape” for the lab business and not a result of the Cigna lawsuit.
Cigna spokesman Joseph Mondy said that the insurer only exited the individual marketplace in Florida, and he said other non-marketplace plans are available there. The company still sells marketplace plans in Arizona because the insurer is “not seeing this type of activity” in Arizona.
In 2013, another insurer, Horizon Blue Cross Blue Shield of New Jersey, sued Florida-based Avee Laboratories and a home for those seeking addiction treatment. The health insurer alleged that the sober house collected and sent patients’ urine samples to Avee, even when such testing wasn’t medically necessary. Avee denied it performed medically unnecessary testing
A Scottsdale-based sober house, Scottsdale Recovery Center, routinely sent urine samples to Avee Laboratory, but it switched to another lab about two years ago because Avee would take too long to complete tests, said Scottsdale Recovery Center co-founder and CEO Alex Salcedo.
Salcedo said Scottsdale Recovery Center, which provides sober-living homes mainly for young adults battling drug and alcohol addiction, typically tests its clients three times a week. The maximum amount billed per test is $1,400, Salcedo said, but he said Scottsdale Recovery often takes lower payments from insurers and consumers don’t pay out of pocket.
Salcedo said the nature of substance-abuse recovery requires frequent testing to make sure patients are not cheating themselves. He said Scottsdale Recovery chose to send urine samples to an out-of-state laboratory because it was among the largest labs in the industry.
Deterrent effect questioned
Some pain-management experts question whether urine drug screens stop abuse or resale of pain pills.
“There is not much evidence that it helps deter use,” said Lynn Webster, past president of the American Academy of Pain Medicine. “Even the CDC (Centers for Disease Control and Prevention) guidelines are recommending urine drug tests, but they don’t state how these will be paid … I have seen bills of $700 to $800 on a monthly basis. It is unaffordable. It is absurd.”
Other doctors say that urine screens are not a fail-safe method to prevent patients from diverting pain pills — filling a prescription and then reselling the pills instead of taking them for pain needs.
Dr. Mohab Ibrahim, a University of Arizona pain specialist, said monthly urine screens can be gamed by a dishonest patient. A patient who takes medicine days in advance of a scheduled urine screen may be able to mask weeks of not using the medication.
“The urine test is mostly performed by physicians to satisfy legal and regulatory grounds, but its medical value as a measure of adherence to a treatment plan is questionable,” Ibrahim said.
Republic reporter Rob O’Dell contributed to this article.
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