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.
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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.
"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.
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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.
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 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.
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