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Medicare on drugs: 24,000 tests for 145 patients

The New York Times Health For Tomorrow Conference

By M.B. Pell and Sharon Begley

(Reuters) - Three Connecticut doctors billed Medicare for nearly 24,000 drug tests in 2012 - on just 145 patients. Despite the extraordinary number, Medicare administrators paid the doctors a total of $1.4 million, according to a Reuters analysis of government payments to health providers.

The three physicians stand out in the Medicare data released last month because they conducted three to four times more drug tests per patient than any other provider in the country. In fact, they ordered so many individual tests, their patients averaged one every other day.

A surge in prescription drug abuse among older Americans has been accompanied by a big increase in urine and blood tests nationwide. Part of an effort to detect that abuse, the tests generate millions of dollars for providers. Medicare, the government insurance system for the disabled and people 65 years and older, is footing the bill.

Medicare administrators declined to comment on the doctors' bills or to say whether they were investigating. But experts in laboratory billing said the high frequency of tests was extremely unusual and underscored the need for Medicare to improve oversight of potentially lucrative drug tests to guard against billing for unnecessary procedures.

Study: Medicare Patients Receiving Unneeded Procedures

"Those numbers are ridiculously high," said Dr Stuart Gitlow, acting president of the American Society of Addiction Medicine. "There is no medical indication I can think of that would require such frequency of testing. I can't come up with a scenario at all."

Two of the doctors work together in New London, Connecticut. The third doctor works in Ellington, about 60 miles away. Two of the three, contacted by Reuters, denied any wrongdoing, with one saying he was simply following Medicare's billing rules as he understood them. The third declined to comment.

Each of the doctors requested only the most expensive and comprehensive drug test, for as much as $94, rather than the simpler $19 one. This was done to improve the accuracy of the results, one said.

"SPIGOT OF MONEY"

Medicare paid medical providers $457 million in 2012 for 16 million tests to detect everything from prescription narcotics to cocaine and heroin, according to the Reuters analysis.

"In some parts of the country every doctor and his cousin is hanging out a shingle to do (addiction) treatment. There's a tailor-made opportunity for ordering a profusion of tests instead of one," said Bill Mahon, former executive director of the National Health Care Anti-Fraud Association.

"It's like turning on a spigot of money," he said.

Urine and blood tests are potential areas of fraud and abuse because guidelines for drug testing are vague, leaving the frequency of testing to the discretion of the provider. Unlike private insurance companies, which sometimes dispute charges and pay providers only when they have vetted a claim, Medicare almost always pays first and asks questions later.

There is often a legitimate need for such drug tests, to determine whether an addict has relapsed or to ensure that patients prescribed painkillers are taking them rather than selling them.

In 2011, the average number of older Americans misusing or dependent on prescription pain relievers grew to about 336,000, up from 132,000 a decade earlier, according to the Substance Abuse and Mental Health Services Administration.

Urine drug testing first showed up on the radar screen of Medicare investigators in 2011. Since then the Office of the Inspector General of Health and Human Services, which oversees Medicare, has settled three cases in which it charged providers whose billings for drug tests were deemed excessive.

When Medicare administrators released the payment data for 880,000 healthcare providers last month, officials said they hoped outside experts would comb through it for possible waste, fraud, and abuse.

DECIPHERING BILLS

Addiction psychiatrist Erum Shahab of Ellington conducted 8,518 drug tests for 43 Medicare patients in 2012, the Reuters analysis found. That's an average of 198 per patient and the most of any Medicare provider in 2012.

Shahab declined to comment on her billing.

Medicare reimbursed her billing number $207,046 for these tests, which detect multiple classes of drugs. Ninety-five percent of her Medicare revenue came from the tests.

New London-based Dr Bassam Awwa, who also specializes in treating addiction, conducted 13,260 drug tests for 90 patients in 2012, or 147 per patient. That's about three per week for every patient. Medicare paid his billing number $983,894.

Dr Ammar Traboulsi, who shares an office with Awwa, was paid for 2,142 drug tests on 12 patients in 2012, or an average 178 tests per patient. Medicare paid his billing number $159,107.

Among the thousands of providers who charged Medicare for drug tests, the next highest number of tests per patient in 2012 was 50. Excluding the three Connecticut doctors, the median number per patient nationwide was 1.3.

"We would never do that many drug screenings here, even in our intensive outpatient treatment center," said Dr Elizabeth Howell, the director of the Addiction Psychiatry Fellowship Training Program at the University of Utah Neuropsychiatric Institute, when Reuters read her the numbers for the three Connecticut doctors.

"There's a big question mark in my mind about what they're doing," she said.

It is not possible to tell from the Medicare data how many providers are fraudulently or wastefully billing for drug tests. For instance, some physicians may be ordering tests on the vast majority of their patients, even those with no history of abuse.

Recent court cases, however, hint at the extent of the problem.

In February, SelfRefind, a chain of addiction treatment centers in Kentucky, agreed to pay $15.75 million to settle allegations that they billed Medicare and Medicaid for drug tests that were medically unnecessary and many times more expensive than other suitable alternative tests, the Department of Justice said in a statement.

HOW TO BILL

Doctors Awwa and Traboulsi run a program in which patients addicted to opioids are given Suboxone, a drug made by Britain's Reckitt Benckiser (RB.L) as a safer substitute, much as heroin addicts are weaned off that drug through methadone.

Awwa said the payment numbers for his practice were correct, but misleading. He conducts drug tests only once a week for patients in the Suboxone program, not the three times per week the Medicare data suggest.

But he billed Medicare separately for each drug he tested. Rather than charging Medicare once to test a patient for ecstasy, ketamine and bath salts, for instance, Awwa charged the program three times.

"This is the way we were told to bill," he said. "We are not doing them artificially to generate revenue."

Traboulsi, in a separate interview, offered similar explanations.

Medicare billing rules effective Jan. 1, 2011, however, prohibit providers from charging for each drug tested.

"If you did one drug, if you did 50 drugs, it should have been times one," said Melissa Scott, a laboratory billing consultant.

Awwa said he believed the guideline was effective as of 2013 and since then has charged Medicare for only one test per patient visit. Medicare has not responded to Reuters' requests for Awwa's 2013 and 2011 billing data.

Medicare uses an automated procedure to halt payments to providers who bill multiple times for the same drug test, according to Rob DeConti, assistant Inspector General of Legal affairs at the Office of the Inspector General. But providers can skirt the automated denials by changing the way they submit their bills.

Awwa said Medicare audited him and found nothing wrong with his laboratory billing practices. Medicare said it does not confirm or deny whether it has investigated any provider.

(Reporting By M.B. Pell and Sharon Begley, editing by Michele Gershberg and Ross Colvin)


Join the discussion

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Pamela May 29 2014 at 4:37 PM

This is what i did for a living, i was an RN/MS and worked to detect Medicaid/Medicare fraud. It is raimped and it is NOT the elderly who are the cause. it truly is greedy doctors who in med school were promised wealth and power.

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6 replies
California Granny May 29 2014 at 3:40 PM

These Charlatans must be put out of business. With their un-honest ways they can bankrupt the whole system. No wonder I have no trust of most doctors anymore, when they can get away with this kind of swindles.

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2 replies
timsalive California Granny May 29 2014 at 8:11 PM

Well when a patient comes to them with multiple issues and DEMANDS every test to find out what is wrong then there you go. Then The govt makes you jump through hoops to do everything their way and then they take kickbacks there you go. Then the Govt cuts your pay by 33% What do you expect? So it seems to me you dont work in the medical field and have no clue what you are talking about. Not all Dr.s are bad but the Govt is tryig to force it that way so they can import cheap Dr's from Pakistan and other third world countries. Yes Third World!

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5 replies
Pearltrans California Granny May 30 2014 at 12:59 AM

Bet they don't get away with it.

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2 replies
jrgumshoe Pearltrans May 30 2014 at 8:56 AM

Most of them do get away with it. Do you realize how easy it truly is. Suppose a patient went to a doctors office and complaining of diarrhea. Now there are hundreds of things that can cause the condition, from foods to cancer. A slick doctor can milk a lot of money from an insurance company for that very common medical condition.

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rwitchwoman63 Pearltrans May 30 2014 at 9:09 AM

Bet they do!

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foxylynx May 29 2014 at 3:57 PM

PROSECUTE TO THE FULLEST EXTENT OF THE LAW and take all their worldly possesions - when they get out they will wish they were back in. Take their license to practice away for good and in every state. These "profit pigs" need to understand that this will not be tolerated!

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2 replies
neryi foxylynx May 30 2014 at 2:59 AM

The Gov,t should take a look at the Medicaid fraud.

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1 reply
poll100 neryi May 30 2014 at 8:34 AM

They refuse to get involved with medicare fraud so have no interest in medicaid fraud.

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pkellycpa foxylynx May 30 2014 at 8:33 AM

Deport them back to whatever Muslim country they come from.

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abudotcom May 29 2014 at 3:43 PM

Welcome to Florida, Medicare Fraud Capital of the USA…

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8 replies
swoodlawn May 29 2014 at 3:54 PM

And this is shocking?!? It is happening all over the U.S in every sector and every business. When are "we" going to stand up and say enough.

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1 reply
Robert Cape swoodlawn May 30 2014 at 1:33 AM

As long as we keep electing crooked morons to govern us, just how can we "stand up and say" anything they would listen to?

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2 replies
Pearltrans Robert Cape May 30 2014 at 2:12 AM

I don't say he's a moron, but what Republican Governor Rick Scott of Florida did when he was head of "Columbia/Hospital Corporation of America looks crooked to me. Google Rick Scott and Medicare Fraud and you will see his corp. settled a Medicare Fraud case for $1.7 billion, largest Medicare fraud case ever. The investigation began in the 1990's and he later resigned in 1997. And he was elected governor and is running agian right now! What kind of people live in Florida who would elect someone like that?

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vlddanny Robert Cape May 30 2014 at 8:24 AM

Robert, most "political" issues are found to be about money when ran through the strainer. So therein is the answer to; how can we "stand up and say" anthing they would listen to?" We fight money with money.

Yesterday government approval hit a new all time low of about 10%. There are 160 million workers in the US. If 90% are fed up with government, a lot of money (taxes, profits, union dues) to get change. Workers must unite peacefully and peacefully stay at home, stopping the money the politicians and their cronies love. We must plan it timely and properly and publicize it. As the day nears for tens of millions to peacefully Occupy Our House to take back our White House, they will agree to work on our to do list. Mainly to get the money (taxes, profits, union dues) flowing again, even if on our terms again.

How do we know it will work? We've seen unions do it forever. They threaten to stay home and most times all it takes is a threat to get what they want.

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LMetz11822 May 30 2014 at 3:55 AM

I am a hospital Administrator and I can tell you that abuse of this type goes on a lot. Of course there are those Physicians that do care about their patients. Then there are also those Physicians who do order a lot of tests either themselves and or through their PA's primarily because certain types of tests will increase their reimbursement.

Physicians are not alone in this, hospitals, nursing homes, home health agencies, DMEs etc, will contract with a number of Physicians and give them some type of a role as a Medical Director and then pay them outlandish fees of $5,000, $10,000 or even $20,000 per month. While the role of the Medical Director can be beneficial to the facility in helping to improve patient care; unfortunately facilities sometimes create different types of MD roles with the understanding between them and the physician that the majority of the patients will be referred to their facility.

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2 replies
p1943ship LMetz11822 May 30 2014 at 8:10 AM

Great post LMetz11822

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davo1941 LMetz11822 May 30 2014 at 9:14 AM

sounds like a violation of the stark law.

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1 reply
LMetz11822 davo1941 May 30 2014 at 1:44 PM

Thanks. You are absolutely correct it is a violation of the Stark Laws. There was a lot more that I could have said, but I was limited because of space. Again, there are good Physicians out there that do care about patient care, but there are also those who are lured by the money and they have no qualms about sacrificing patient care to obtain it. People need to make themselves more aware and should change Physicians and/or other services if they aren't getting the care that they need.

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talk2tim5 May 29 2014 at 7:59 PM

my dads doctor has him about every month for blood work , than has him come back just to get results. I believe it is to charge him again. Dad is 90 years old and dont get around good. They could give the results over the phone , but than they could'nt charge medicare i guess.

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4 replies
rockymtnhikerCo May 29 2014 at 4:22 PM

Oversight,you have to be kidding,this story,has been told time and time again,fraud applied to Medicaid,medicare,it STILL business as usual.And of course,medicare administrators refuse to tell us whether these billing charges are being investigated. This a partly a reason I don't pay that much attention to news anymore,it seems to be the same old broken record.

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1 reply
abcstarfox rockymtnhikerCo May 30 2014 at 12:23 AM

Good post.

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fawndls May 29 2014 at 7:34 PM

one day ,even the doctors won't have health coverage because they continually cheat Medicare with their greed and there will be no more hospitals in operation because of stealing money from Medicare, Call it what it is and not a fancy term like fraud. One greedy guy covers for the next greedy guy and we all fall down. It's actually Biblically called SIN................

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dvdscrscsn667 May 29 2014 at 6:26 PM

Anyone with an elementary education can see what the real problem is in America. And continuing to attack the common people will not solve it.

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1 reply
savannahswithgod dvdscrscsn667 May 30 2014 at 8:43 AM

It's the Dollar rules! You got none on the street, they'll toss the kids out there too with you and not give a dam. Let's see AT&T. Cute broad with the 160 a month plan. 1,600 a year. And I work as a delivery driver for Dominoes making 12 thou a year. Yeh I can afford that plan? Oh and the water resistant phone from Samsung or whoever the Hell. In this age and time they can't make it water proof?

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