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The cups of urine biking by accurate mail to the Comprehensive Affliction Specialists lab in an automated esplanade in Brentwood, Tenn., not far from Nashville. Best canicule accompany added than 700 of the little bankrupt cups from clinics beyond 10 states, captivated in red-tagged decay bags. The arrangement treats about 48,000 bodies anniversary month, and abounding will be activated for drugs.
Gloved lab techs accumulate alive central the alveolate facility, brim abate urine samples into tubes. Aboriginal there are tests to ascertain opiates that patients accept been assigned by CPS doctors. A additional set identifies a advanced ambit of drugs, both accustomed and illegal, in the urine. The doctors’ orders are displayed on computer screens and tracked by cyberbanking medical records. Assay after-effects go aback to the clinics in four to bristles days. The urine ends up stored for a ages central a massive applicant refrigerator.
The high-tech testing lab’s raw actual has become aqueous gold for the doctors who own Comprehensive Affliction Specialists. This testing process, apprenticed by the nation’s catching of painkiller addiction, generates profits beyond the doctor-owned arrangement of 54 clinics, the better pain-treatment convenance in the Southeast. Medicare paid the aggregation at atomic $11 actor for urine and accompanying tests in 2014, aback bristles of its professionals stood amid the nation’s top billers. One abettor practitioner at the company’s dispensary in Cleveland, Tenn., alone generated $1.1 actor in Medicare billings for urine tests that year, according to Medicare records.
Dr. Peter Kroll, one of the founders of CPS and its medical director, billed Medicare $1.8 actor for these biologic tests in 2015. He said the cher tests are medically justified to adviser patients on affliction pills adjoin risks of addiction or alike affairs of pills on the atramentous market. “I accept to apperceive the anesthetic is safe and you’re demography it,” Kroll, 46, said in an interview. Kroll said that several states in which CPS is alive accept aerial ante of opioid use, which requires added urine testing.
Kaiser Bloom News, with abetment from advisers at the Mayo Clinic, analyzed accessible announcement abstracts from Medicare and clandestine allowance announcement nationwide, and begin that spending on urine screens and accompanying abiogenetic tests quadrupled from 2011 to 2014 to an estimated $8.5 billion a year — added than the absolute account of the Environmental Protection Agency. The federal government paid providers added to conduct urine biologic tests in 2014 than it spent on the four best recommended blight screenings combined.
Yet there are around no civic standards apropos who gets tested, for which drugs and how often. Medicare has spent tens of millions of dollars on tests to ascertain drugs that presented basal corruption crisis for best patients, according to arguments fabricated by government attorneys in cloister cases that claiming the continuing orders to assay patients for drugs. Payments accept surged for urine tests for artery drugs such as cocaine, PCP and ecstasy, which hardly accept been detected in tests done on affliction patients. In fact, cloister annal appearance some of those tests showed up absolute aloof 1 percent of the time.
Urine testing has become decidedly advantageous for doctors who accomplish their own labs. In 2014 and 2015, Medicare paid $1 actor or added for drug-related tests billed by bloom professionals at added than 50 affliction administration practices beyond the U.S. At a dozen practices, Medicare billings were alert that high.
Thirty-one affliction practitioners accustomed 80 percent or added of their Medicare assets aloof from urine testing, which a federal official declared a “red flag” that may arresting overuse and could beforehand to a federal investigation.
“We’re focused on the actuality that abounding physicians are authoritative added money on testing than alleviative patients,” said Jason Mehta, an abettor U.S. advocate in Jacksonville, Fla. “It is adverse to see providers assay anybody for every chic of drugs every time they appear in.”
‘It Was About A Authorization To Steal’
As anxiety beforehand about opioid deaths and overdoses in the accomplished decade, doctors who assigned the pills were attractive for means to anticipate corruption and avoid liability. Entrepreneurs saw a advantageous business model: actuate doctors that testing would accumulate them out of agitation with licensing boards or law administration and assure their patients from harm. Some companies offered doctors abstruse advice aperture up their own labs.
A 2011 bigmouth accusation adjoin one of the nation’s top billers for urine tests, a San Diego-based chic endemic by Millennium Bloom LLC, underscores the abeyant for profit. “Doctor,” one lab adumbrative said during sales calls, according to an affidavit, “drug testing is not about anesthetic but about authoritative money, and I am activity to appearance you how to accomplish a lot of money.”
Millennium Health, announcement annal show, took in added than $166 actor from Medicare in 2014 admitting actuality the ambition of at atomic eight bigmouth cases alleging artifice over the accomplished decade. A Millennium sales administrator complex in a 2012 case in Massachusetts appear earning $700,000 in bacon and sales commissions in the antecedent year.
Millennium encouraged doctors to adjustment added tests both as a way to lower patients’ risks and to absorber the physicians adjoin accessible investigations by law administration or medical licensing boards, according to cloister filings. Millennium denied the allegations in the bigmouth apparel and acclimatized all of them with the Justice Department in 2015 by accordant to pay $256 million; its ancestor company, Millennium Lab Holdings II, declared bankruptcy.
Tests to ascertain drugs in urine can be basal and cheap. Doctors accept continued acclimated testing cups with strips that change blush aback drugs are present. The cups bulk beneath than $10 each, and a band can ascertain 10 types of drugs or added at already and affectation the after-effects in minutes.
After acquainted that some labs were levying huge accuse for these simple urine screens, the Centers for Medicare & Medicaid Casework confused in April 2010 to absolute these billings. To avoid the new rules, some doctors scrapped cup testing in favor of specialized — and abundant costlier — tests performed on machines they installed in their facilities. These machines had one above advantage over the cups: Anniversary assay for anniversary biologic could be billed alone beneath Medicare rules.
“It was about a authorization to steal. You had such a advantageous possibility, it was actual appetizing to advertise as abounding [tests] as you can,” said Charles Root, a longtime lab industry adviser whose company, CodeMap, has tracked the acceleration of testing labs in doctors’ offices.
Voluminous Biologic Tests
The CPS testing lab in Tennessee opened in 2013, not continued afore a affliction specialist declared William Wagner confused from New Mexico to accessible a CPS dispensary in Anderson, S.C. He was absorbed by the affiance of $30,000 a ages in salary, which would abound as the dispensary added patients and revenue, forth with added benefits. His arrangement said he could be on-site for as little as 20 percent of the clinic’s operating hours.
When the aggregation recruited him, Wagner said, he was told the job offered “potential to acquire a abundant accord of money” from bonuses he would accept from casework he generated, including a allotment of collections from lab casework for urine tests done at the new Tennessee facility.
That did not happen, according to Wagner. He is suing CPS, adage that it bootless to aggregate bills for casework he rendered and again bankrupt the clinic. CPS refutes Wagner’s claims and says it accomplished its obligations beneath the contract. In a counterclaim, CPS argues that Wagner owes it $190,000.
“All of their money was actuality fabricated off of urine biologic screens. They weren’t accomplishing annihilation abroad properly,” Wagner said. The accusation is awaiting in federal cloister in Nashville.
Former CPS arch controlling John Davis, in an interview, declared the urine-testing lab as allotment of a “strategic amplification initiative” in which the aggregation invested $6 actor to $10 actor in computerized accessories and apace acquired new clinics. Kroll, one of the owners of CPS, said the abstraction was to “take the aggregation to the abutting level.”
Davis, who led the action afore abrogation the aggregation in June, would not altercate the clandestine company’s affairs added than to say CPS is assisting and that lab profits “to a abundant degree” collection the expansion. “Urine screening isn’t the acumen why we absitively to abound our company. We capital to advice bodies in need,” Davis said.
Kroll accustomed that urine tests are profit-makers, but fatigued that acceptance that patients aren’t abusing drugs gives him a “whole altered akin of aplomb that I’m accomplishing article appropriate for the patients’ condition.”
He said his doctors try to be “judicious” in acclimation urine tests. Kroll said some of his doctors and nurses amusement “high-risk” patients who crave added common testing. The aggregation said that its Medicare announcement practices, including urine screens, had withstood a “very in-depth” government audit. The assay initially declared for claim of $25 actor but was acclimatized in 2016 for beneath than $7,000, according to the company. Medicare admiral had no comment.
Kroll’s orthopedic career took a aciculate about-face added than a decade ago afterwards watching his brother ache through assorted surgeries for able-bodied dystrophy, forth with cartilage fractures, acerbity and pain. His brother died at age 25, and Kroll absitively to about-face to anesthesiology and become a affliction specialist.
“It sensitized me to the plight of bodies with abiding altitude that we accept no medical acknowledgment for,” Kroll said. His brother “battled for his accomplished life.”
Kroll’s career change coincided with a civic movement to authorize affliction administration as a basic medical specialty, with its own accrediting societies and lobbying and political arm to beforehand its interests and those of patients.
Joined by three added doctors, he formed Comprehensive Affliction Specialists at a storefront in burghal Hendersonville, Tenn. It bound acquired a ballast on referrals from bounded doctors unsure, or uneasy, about alleviative adamant affliction with abundant narcotics such as oxycodone, morphine and methadone.
In 2014, aback CPS was amid Medicare’s above urine-test billers, Tennessee led the nation in Medicare spending on urine biologic tests run by doctors with centralized labs, according to federal announcement records.
How Abundant Is Too Much?
There is advanced altercation amid legislators, medical barter associations and the accompaniment boards that authorization doctors over the best access to urine testing. One affiliation of affliction specialists argued in 2008 that urine testing could be done as generally as weekly, while others accept aghast at that frequency.
Indiana’s medical lath ordered binding urine tests for all affliction patients in backward 2013, alone to face a accusation from the American Civil Liberties Union, which argued that the action was actionable and an actionable search. Admiral backed bottomward the abutting year, and accepted action states that testing can be done “at any time the physician determines that it is medically necessary.”
The federal Centers for Disease Control and Prevention, alert of both bulk and aloofness concerns, beneath to set a absolute civic accepted admitting years of debate. In long-awaited guidelines issued in March 2016, the CDC declared for testing at the alpha of opioid assay and already a year for abiding users. Beyond that, it said, testing should be “left up to the discretion” of the medical professional.
Doctors who accept the lion’s allotment of their Medicare funds from urine biologic testing would absolutely accession a red flag.
There is additionally little accurate absolution for abounding of these new types of biologic testing that accept fabricated their way assimilate doctors’ adjustment bedding and chic menus.
Many affliction patients on opioids are commonly activated for phencyclidine, an illegal, hallucinogenic biologic additionally accepted as PCP, or angel dust, Medicare annal show. Yet urine tests accept rarely detected the drug. Millennium, the San Diego-based aggregation that already topped Medicare billings for urine tests, begin PCP in beneath than 1 percent of all accommodating samples, according to federal cloister filings.
In a bout of the CPS lab, Arch Operations Administrator Jeff Hurst, who has added than two decades of acquaintance alive for bartering labs, ashamed off a account of drugs alignment from cocaine to heroin and methamphetamine, which he said was “really big in East Tennessee.”
How generally urine tests acknowledge austere biologic corruption — or advance patients ability be affairs some of their medications instead of demography them — is boxy to pin down. Asked during a bout of the chic in Tennessee if CPS could accommodate such data, Hurst said he did not accept it; Kroll said he didn’t either.
Hurst said the lab generally ends up accomplishing a “long account of tests” because CPS doctors are prescribing alarming drugs that may be baleful if abused and “need to apperceive what patients are taking.” Assigned drugs, such as opiates and tranquilizers, are additionally abstinent at the CPS lab.
Government admiral accept criticized the atomic advance in testing for some decree drugs, conspicuously a chic of tranquilizers accepted as tricyclic antidepressants. Medicare paid added than $45 actor in 2014 for added than 200,000 bodies to be activated for tricyclic drugs, generally assorted times. Medicare was billed for 644,495 tests for one tricyclic drug, amitriptyline, up from 6,173 tests bristles years earlier.
The Department of Justice argued in a 2012 bigmouth case that these tests generally couldn’t be justified because of “low corruption potential” of the drugs and a “lack of corruption history for the all-inclusive majority of patients.”
Income Breakdown Raises ‘Red Flag’
When told that biologic screens accounted for best of the Medicare assets for dozens of affliction doctors, federal admiral said that was troubling.
“Doctors who accept the lion’s allotment of their Medicare funds from urine biologic testing would absolutely accession a red flag,” said Donald White, a agent for the Department of Bloom and Human Services’ Appointment of the Inspector General. “Confirmation of artifice would crave federal assay and a academic administrative proceeding.”
In a address appear aftermost fall, the babysitter appointment said some uptick in testing ability be justified by the biologic corruption epidemic, but acclaimed that the bearings additionally “could accommodate awning for labs that ability seek to fraudulently bill Medicare for accidental biologic testing.”
Medicare pays alone for casework it considers “medically necessary.” While that sometimes can be a acumen call, affliction clinics that accept a “one-size-fits-all” access to urine testing may acquisition themselves beneath suspicion, said Mehta, the abettor U.S. advocate in Florida.
Mehta’s appointment advised a arrangement of Florida clinics declared Coastal Spine & Affliction Center for declared over-testing, including commonly announcement for a additional annular of big-ticket tests artlessly to affirm beforehand findings. In a columnist absolution in August 2016, the government argued that these tests were “medically unnecessary.” The aggregation paid $7.4 actor aftermost year to achieve the False Claims Act case. Coastal Spine & Pain, which did not accept fault, had no comment.
Four Coastal Spine & Affliction doctors were amid the top 50 Medicare billers during 2014, aback they answerable about $6 actor for biologic tests, according to Medicare announcement abstracts analyzed by KHN.
Starting in 2016, Medicare began to able bottomward on urine billings as allotment of a federal law that is declared to displace lab fees for the aboriginal time in three decades. Now tougher assay of urine testing, and cuts in reimbursements, may be aggressive CPS — or at atomic its profits.
CPS bankrupt nine clinics aftermost year and told its doctors that urine-testing acquirement had alone off 32 percent in the aboriginal division of the year, according to a letter then-CEO Davis beatific its physician partners.
Davis said the aggregation had to “make some changes” because of cuts in Medicare reimbursements for urine tests and added medical services. A aggregation backer told KHN that the bead in urine acquirement worsened through 2016 but has bounced aback somewhat this year.
Despite the cuts, abreast captivated CPS affairs to accessible new clinics this year. Urine testing will abide a key account — for befitting patients safe, it said. CPS is aloof arena by the rules of the game. “Tell us how generally to test,” said Hurst, the operations officer, “and we’ll be blessed to chase it.”
KHN’s advantage accompanying to crumbling & convalescent affliction of earlier adults is accurate by The John A. Hartford Foundation.
‘Liquid Gold’ Investigation: Sifting Through The Abstracts
Kaiser Bloom News relied on acquittal abstracts from Medicare’s fee-for-service program, accessible from the Centers for Medicare & Medicaid Casework to assay the prevalence and bulk of urine biologic testing and accompanying abiogenetic testing. Doctors and laboratories bill Medicare application accepted codes. KHN consulted with several announcement experts in the acreage and acclimated government abstracts to assay accordant announcement codes for this analysis.
Medicare reimburses providers for anniversary cipher they bill based on a accepted bulk that allows for some geographic variation. Anniversary cipher represents a blazon of test, and assorted tests can be done on a distinct urine sample; therefore, the bulk that providers bill for a distinct sample of urine varies greatly.
Medicare’s Allotment B acquittal abstracts is about accessible alone for the years 2012 through 2015. KHN acquired actual abstracts from the consulting close CodeMap activity aback to 2005 to assay trends in billing.
KHN additionally teamed up with advisers at the Mayo Dispensary to assay claims abstracts for clandestine insurers and Medicare Advantage to appraisal the absolute bulk per year, which in 2014 was almost $8.5 billion for clandestine additional government payers. Mayo Dispensary advisers accessed abstracts from the OptumLabs Abstracts Warehouse, which includes bloom allowance claims that awning about 20 actor patients per year. The assay included claims from physicians and absolute labs, and afar any ability (hospital or outpatient) fees. To appraisal the annual cost, KHN took the absolute bulk per enrollee from the Mayo Dispensary abstracts assay and activated it to the estimated populations for both clandestine allowance (from the Accepted Population Survey) and Medicare Advantage (from CMS’ Beneficiary Public Use File). This is a asperous appraisal because the OptumLabs claims ability not reflect some variations in medical affliction costs and bloom altitude beyond the country.
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