Government statisticians using “Big Data” began noticing that some providers were giving lots of tests to the elderly to detect illegal drugs and then billing Medicare. Prosecutors then went after some outliers.
On August 31, 2016, one such outlier, Physicians Group Services, P.A., doing business as Coastal Spine and Pain based in Jacksonville, Florida, agreed to pay $7.4 million to the government to resolve allegations that Coastal violated the False Claims Act by performing medically unnecessary drug screening procedures.
Testing Elderly for Heroin, Cocaine and Ecstasy
The practice billed Medicare and TRICARE for “Quantitative Drug Tests” (QDT). Those tests are expensive tests to identify and count particles of illicit drugs such as ecstasy, cocaine and heroin in elderly patients. The government claimed the tests were unnecessary.
But according to the settlement, the government says the company knew or should have known the tests were “not medically reasonable or necessary.”
As an example, the practice included testing 80-year-olds for exotic and illegal drugs, first with a test to detect the presence of those and other more common drugs and then, even when no evidence was found, with a much costlier screen that would detect the exact quantities of those drugs in the person’s system.
The government said the initial set of tests which would detect the presence of drugs and cost only hundreds of dollars, is a reasonable action for a pain management clinic. But what Coastal did, according to prosecutors, is that regardless of what these results were, they took the urine and they put it into a very sophisticated machine that they bought and did what they called confirmatory testing. “They confirmed that the results they had in their point of care cup were accurate. And that is thousands of dollars, not hundreds of dollars, ” said prosecutors.
Every patient was tested every time for every drug, said Jason Mehta an assistant U.S. attorney in Jacksonville.
“Even if the results were negative, they ran this very sophisticated, very expensive test to confirm that the tests were negative, ” said Mehta.
According to the U.S. Justice Department, QDTs are appropriate only if there is reason to doubt the more general and cheaper qualitative drug test screens. The government contends that Coastal appropriately performed qualitative drug tests for its patients. However, regardless of the result of the less expense qualitative test, Coastal performed and billed for quantitative drug tests for all patients. The government contends this was medically unnecessary, as there was no reason to question or further confirm previous qualitative urine drug testing screens.
Busted by Statisticians
The statisticians caught Coastal through the proactive review of claims data. Coastal was a statistical outlier in terms of billing for quantitative drug test screens. In fact, in each and every instance that Coastal billed for a qualitative drug test screen, it also billed for a quantitative drug test screen. This statistical outlier prompted questioning and investigation by the Department of Justice.
“New and expanded uses of data analytics to identify suspicious billing patterns, such as in this case, are providing law enforcement agencies with powerful investigative tools to combat fraud and abuse in federal health care programs, ” said HHS OIG SAC Shimon Richmond. “Medicare should only be paying for medical tests to improve the health of beneficiaries, not the profit margins of unscrupulous physicians. Today’s settlement should serve as notice to others that fraud will be vigorously pursued.”
The fine was double the amount the company billed for tests conducted from August 2015 to February 2016.
The company’s attorney issued a statement saying management said it decided to settle the matter “to avoid expensive and protracted litigation and to allow us to focus on our patients.” The company was ready to defend the appropriateness and medical necessity of the quantitative testing, the statement said.
New guidelines governing protocols for how such tests are conducted were implemented in mid-August 2015 after Medicare noticed widespread billing for double tests.
“They started seeing, all across the country, individuals, elderly, above the age of 65, are getting tested in extreme quantities, ” Mehta said. “And it just doesn’t make sense.”
