Unnecessary Pathology Special Stains: When the Workflow Replaces the Decision

Unnecessary pathology special stains can generate false Medicare claims when a practice automatically adds them before a pathologist reviews the routine H&E stain and determines whether the patient needs more testing. The added service is already underway before the professional decision that should justify it. A pathologist sees the review sequence. A histology technician sees the staining instructions. A biller sees the additional charge.

Routine H&E Review and the Reason for Another Stain

In the government’s special-stain cases, the alleged shortcut was to perform additional stains before the pathologist reviewed the routine stain and decided whether more staining was medically necessary.

The Medicare Benefit Policy Manual ties additional stains under its anatomic pathology exception to a complete and accurate diagnosis, a documented reason and communication of the results to the treating physician. The professional judgment has a purpose: completing the diagnosis for that patient.

For an insider, the useful comparison is between what the pathologist decided and what the laboratory had already done. A routine instruction can send tissue through additional staining before that patient-specific assessment. When the practice bills Medicare for unnecessary stains, taxpayers pay for the laboratory’s routine.

Who Chose the Condition in a Reflex Order?

Medicare’s manual describes a treating physician setting the condition for an additional test for a particular patient. In Atlanta Gastroenterology’s case, the government alleged that a blanket or reflex ordering process selected special stains automatically, before a pathologist reviewed the routine stain or determined the patient’s need.

A standing template can repeat that selection across patients. The person receiving the specimen may be following an instruction established well before that specimen arrived. With you, we examine who set that instruction and what triggered the extra work, because those choices connect a laboratory routine to the services billed.

Piedmont Pathology and the Pathologist Who Saw the Sequence

Piedmont Pathology agreed to pay $601,000 in May 2017 to resolve allegations that it submitted false claims to Medicare and Medicaid for medically unnecessary procedures. The Justice Department’s announcement identifies the whistleblower as a pathologist who had worked for the practice.

The department described allegations involving certain gastric biopsies. Special stains had been performed before a pathologist reviewed the routine H&E-stained specimen. The government joined the whistleblower’s case and pursued the claim that those additional stains lacked medical necessity.

Special stains were billed separately to government health care programs. The alleged practice performed the extra stain before the pathologist decided whether the patient needed it. The bill followed a laboratory routine that had already made the choice.

Someone who interprets the tissue can explain what was available at the first review, whether an additional stain had already been performed and what the review actually called for. That professional knowledge connects a laboratory routine to a specific allegation about unnecessary testing.

Atlanta Gastroenterology and Automatic Special-Stain Orders

Atlanta Gastroenterology Associates, a gastroenterology practice, allegedly had special stains ordered before a pathologist reviewed the routine H&E slide. The practice agreed to pay $4.75 million in February 2026 to resolve allegations involving both unnecessary gastrointestinal pathology services and kickbacks for referrals.

The Justice Department alleged that the practice contracted with Advanced Pathology Solutions to construct and operate a limited-capacity pathology laboratory in its office. Histology technicians prepared and stained slides there. Atlanta Gastroenterology billed Medicare and other insurers for the technical component, while Advanced Pathology Solutions interpreted the slides and billed for the professional component.

The United States alleged that the practice received benefits connected to the laboratory’s setup and operation in exchange for exclusive referrals to Advanced Pathology Solutions. The practice could bill for preparing the additional slides while another business performed the interpretation.

The special-stain allegation concerned what happened before interpretation. The government alleged that Atlanta Gastroenterology used blanket or reflex orders to add special stains automatically, without a pathologist first reviewing the routine stain and deciding whether the particular patient needed additional stains. It also alleged that the medical record lacked justification for the added stains.

Advanced Pathology Solutions and its owners agreed in June 2026 to pay $30 million to settle allegations of kickbacks and unnecessary testing. For an insider in an in-office laboratory, the work and the billing can span both the practice and the outside pathology company.

The Order, the Slide Sequence, the Report and the Claim

The useful evidence connects the added stain to its instruction, its clinical reason and its bill. Requisitions and standing instructions describe what was requested. Slide logs or order histories, where they record timing, can show whether the additional work preceded the pathologist’s review. The pathology report and medical record supply the diagnostic reason, while the claim shows the service charged.

Those records can sit in different offices. Medicare’s documentation requirements put the medical-necessity record with the ordering clinician and the received information and claim documentation with the billing entity. A pathologist, technician and biller each see part of the work. We bring those accounts together with you to establish who directed the added testing and how it reached the payer.

What the Laboratory’s Own Controls Can Show

Written policies, requisitions and reviews of test use show how a laboratory expected its staff to choose, perform and bill services. Comparing those policies with the working instructions can expose how extra staining became routine.

Model Plan Helps Laboratories Fight Fraud, published in Laboratory Medicine in 1997, describes the Office of Inspector General’s recommendations for requisition forms, standing orders and test-use monitoring. The article explains that uniform requisitions should give the physician space to document the medical necessity of each test. It also describes monitoring standing orders for continued validity and analyzing which tests the laboratory performs.

In a special-stain inquiry, we compare the stated ordering policy with what technicians were instructed to do and what pathologists actually reviewed. An insider who knows why the same stain keeps being added can connect the repeated charge to the person or policy that made it routine.

A Whistleblower Case About the Testing Decision

A pathology whistleblower can bring firsthand knowledge of how an added service became a claim.

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

When the Added Stain Was Already Decided

If you know a pathology workflow that selected extra stains before the pathologist made the decision, talk to our whistleblower experts about who controlled that testing. We work with you to build your strongest pathology whistleblower case around the ordering instructions, clinical review and billing, and bring in healthcare fraud whistleblower lawyers who understand pathology services. We stay beside you as your knowledge of the laboratory becomes the foundation of the case.