Coastal Spine and Pain, an operator of 10 pain-management clinics in the Jacksonville, Fla., area, has agreed to pay the U.S. government $7.4 million to settle a False Claims Act lawsuit alleging its clinics performed medically unnecessary and costly drug screening procedures to boost its reimbursements from Medicare and other federal health care programs.
The settlement relates to Coastal’s routine use of “quantitative drug tests,” which identify and count particles of illicit drugs in a patient’s urine. The use of these very specific and extremely costly tests is appropriate only when there is reason to doubt the results of more general and cheaper “qualitative” drug tests.
The government alleged that Coastal appropriately performed qualitative drug tests for its patients, but regardless of the result of the less expense qualitative test, Coastal performed and billed for quantitative drug tests for all of its patients. The government claims Coastal’s routine use of the expensive tests was inappropriate and unnecessary since there was no reason to question or further confirm previous qualitative urine drug test results.
This False Claims Act case was developed through the government’s review of claims data. According to the U.S. Justice Department, Coastal was “a statistical outlier” in terms of quantitative drug billings. Federal prosecutors said that “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.”
These unusual billings raised red flags about potential billing fraud that the government’s Health Care Fraud Prevention and Enforcement Action Team (HEAT) agents picked up on. The data was then turned over to the Justice Department for further questioning and investigation.
“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 Health and Human Services Department special agent Shimon Richmond. “Medicare should only be paying for medical tests to improve the health of beneficiaries, not the profit margins of unscrupulous physicians.”