Connecticut Addiction Medicine: Unnecessary Presumptive Testing Alongside Definitive Tests

The Connecticut Addiction Medicine settlement required the practice and its physician owners to pay $1,002,481 over allegations that they billed Medicare and Medicaid for unnecessary in-office urine drug screens. The government said the same specimens also went to an independent laboratory for definitive testing. For someone who knows the ordering or billing inside an addiction-treatment practice, the question is concrete: what did the office screen contribute to that patient’s care?

Connecticut Addiction Medicine provided behavioral health and addiction medicine services to Medicare and Medicaid beneficiaries at offices throughout Connecticut. The government’s account of the testing and billing puts the practice and its physician owners at the center of the case. According to that account, they ordered the tests, received the reference laboratory’s results and billed for office tests the government alleged were unnecessary.

What Presumptive and Definitive Urine Tests Do

The government alleged that the office screen added nothing to patient care once the reference laboratory’s definitive result on the same specimen was available, which in many cases was within four days.

The In-Office Test Was the Challenged Claim

The government alleged that Connecticut Addiction Medicine billed for unnecessary presumptive screens while also ordering and receiving definitive results on the identical specimens. The conduct covered by the settlement ran from December 21, 2015, through August 31, 2017.

According to the Justice Department, the practice regularly tested patients’ urine in-house and sent every specimen to an independent reference laboratory for definitive testing. In many cases, the outside results arrived in four days or less. The government said those more detailed and reliable results were available to assess and treat the patients.

The government alleged that the practice and its physician owners knew, or should have known, that the presumptive tests were unnecessary. The alleged problem was a charge for an office screen when more detailed results from the same specimen were already available for the patient’s care.

We work through the timing and use of those results with insiders who know what happened between the specimen collection and the bill.

When Are Toxicology Tests Unnecessary?

Toxicology tests are unnecessary when they lack a patient-specific clinical purpose, including when a routine testing schedule generates tests the patient does not need. In Connecticut Addiction Medicine’s case, the government challenged the need for the office screen alongside the definitive result already ordered for that specimen.

Medicare’s diagnostic-testing rule connects the order to the clinician treating the patient’s specific medical problem and using the result in its management. The ordering clinician maintains the medical-necessity documentation in the patient’s record. That makes the chart part of the billing story, even when a laboratory holds the requisition and the result.

The clinical guide adds a distinction that a fixed testing routine can erase. In its addiction-treatment discussion, it says testing at every visit is often unnecessary for stable patients and describes testing frequency changing with the patient’s behavior and progress. It also describes clinics separating specimen collection from the decision to send a test:

A specimen can be collected without making every available test part of the order. The patient-specific decision is easy to lose when collection, test selection and billing become one routine.

Automatic Confirmation in Another Complaint

In a separate case involving Blue Waters Assessment & Testing Services, whistleblowers alleged that court-compliance urine testing generated additional confirmation tests without an individualized clinical assessment. Their complaint described the recurring selection this way:

The alleged routine supplied the next test without a patient-specific reason for it. Connecticut Addiction Medicine’s case focused on the office screen, while this complaint challenged additional confirmation testing. Both put the purpose of the particular billed test at the center of the allegation.

The Connecticut Addiction Medicine Settlement

The Justice Department announced the civil settlement on June 25, 2021. Connecticut Addiction Medicine and its physician owners agreed to pay the federal and state governments to resolve allegations of Medicare and Medicaid overpayments.

The government tied the resolution to the in-office presumptive testing claims. That focus matters to people who work on the practice side of laboratory billing: the allegation followed the ordering and billing decisions inside the office, even though an independent laboratory performed the definitive tests.

What the Order, Result and Claim Show Together

We help insiders connect the clinical reason for a test with the service billed, including paired office and reference-laboratory testing like the workflow described in the Connecticut allegations.

The documentation can sit in different places. Medicare’s rules put the medical-necessity record with the ordering clinician, while the entity submitting the claim keeps the ordering information it receives and documentation that the claim reflects it. A billing record can show the service charged without showing the clinical reasoning recorded in the chart. We work with insiders to connect those parts of the account.

If you worked in specimen collection, clinical care, laboratory operations or billing, you may know where the actual testing departed from the patient’s needs. You may have seen how an order became routine or which results reached the treating clinician. Those details can give a healthcare fraud case its substance: the decisions behind the claims, and who understood what was being billed.

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

You Know How the Testing Was Ordered

If the same specimen routinely generated an office screen and an outside test without a clinical reason for both, speak to one of our whistleblower experts about what you saw. We build the case with you and bring in health care fraud whistleblower lawyers who understand laboratory billing and addiction-treatment testing. We stay beside you through the process, turning your knowledge of the practice into your strongest laboratory billing whistleblower case.