Pubdate: Sun, 27 Dec 2015
Source: Arizona Republic (Phoenix, AZ)
Copyright: 2015 The Arizona Republic
Contact: http://www.azcentral.com/arizonarepublic/opinions/sendaletter.html
Website: http://www.azcentral.com/arizonarepublic/
Details: http://www.mapinc.org/media/24
Author: Ken Alltucker
Bookmark: http://www.mapinc.org/testing.htm (Drug Testing)

LUCRATIVE DRUG TESTS RAISE SOME QUESTIONS

Labs, Doctors Scrutinized Over Routine Screenings

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 of $660. Smith's health 
insurer paid two-thirds of the bill, but he had to pay the balance of 
$219. He decided monthly tests and 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 the state. He had a urine test that checked for10 
substances, including illegal drugs such as methamphetamine, cocaine 
and phencyclidine, more commonly known as angel dust. The man was 
billed separately for each substance tested 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 them and don't mix them 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.

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, said a spokesman for the Centers for Medicare and 
Medicaid Services.

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, 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: We 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 of1,211Arizonans 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 
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 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 healthcare 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.

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 the insurer exited the individual 
marketplace only 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" here.

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 took too long to complete tests, 
said 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 substanceabuse 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.

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 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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MAP posted-by: Jay Bergstrom