Northern Kentucky Center for Pain Relief: The Machine Failed, the Billing Continued

At Northern Kentucky Center for Pain Relief, a medical director and clinic owner billed for unnecessary tests while a poorly maintained analyzer produced false drug positives, according to the Department of Justice’s account of evidence at the criminal trial. The machine falsely suggested patients had taken ecstasy or heroin. The billing continued.

The practice operated in Florence, Kentucky. Its medical director was a physician, and its owner was a licensed chiropractor. The Department of Justice said the scheme defrauded Medicare, Medicaid and commercial insurers of over $4 million for medically unnecessary urine drug testing. The case connects decisions in the treatment room, the laboratory and the billing office. An employee who knew how the machine was maintained could see something an insurance claim would never explain.

The Order, the Analyzer and the Claim

In its account of the criminal trial, the Department of Justice said the clinic’s expensive testing machine malfunctioned because it was not properly maintained. The owner and medical director continued the scheme while that machine produced false positives. For an insider, the useful connection is between the equipment problem, the decisions to keep testing and the bills that followed. A claim can look routine while the people working beside the instrument know the result cannot be trusted.

At Northern Kentucky Center for Pain Relief, insurance proceeds from urine drug testing came to comprise three-quarters of the clinic’s revenue, according to the Department of Justice’s account of the criminal case. The failing machine supported the service responsible for most of the practice’s income.

Under Medicare’s diagnostic-testing rule, the treating practitioner orders the test and uses the result to manage the patient’s medical problem. The practitioner keeps the medical-necessity documentation in the patient record. The billing entity keeps the information it received and documentation that its claim accurately reflects that information.

Those responsibilities put different parts of the story in different hands. A billing employee may see the order and code. A clinician may know why the test was requested and whether its result influenced treatment. A laboratory employee may know what happened between the specimen arriving and the result leaving the machine.

Can a Toxicology Report Be Wrong?

In the Kentucky criminal case, the government identified inadequate machine maintenance as the cause of false positives.

The Journal of Family Practice review is direct about letting a single screen determine care:

A result suggesting heroin or ecstasy use can influence how a clinician understands a patient’s condition and medication use. Here, the machine was generating that suggestion falsely. Taxpayers paid for unnecessary testing that falsely suggested patients were using street drugs.

What an Insider Can Connect

We connect what you know about the patient’s reason for testing with the laboratory’s actual work and the claim sent for payment. With you, we examine how equipment problems and decisions to keep testing carried through to the bills.

These are different views of the same work. The person processing claims may never touch the analyzer. The person handling specimens may never see a payment. Our work is to connect what each insider knows to the conduct behind the government bill.

The Verdict and the Whistleblower Opportunity

On March 23, 2023, a federal jury convicted both the medical director and the clinic owner of health care fraud. The owner was also convicted of conspiracy to commit health care fraud.

If you see similar conduct where you work in healthcare, false bills to Medicare and Medicaid can be the basis of a civil whistleblower case. We examine the orders, testing practices and billing together, with laboratory fraud whistleblower lawyers who understand how those pieces support a case.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Saw What the Machine Was Doing

If you saw unreliable results leave the laboratory while the bills kept going out, talk with our whistleblower experts about the testing you know. We build the case with you, bring in laboratory fraud whistleblower lawyers who understand urine testing and medical necessity, and stand with you throughout the case.