Access Hospital Dayton: Lab Tests With No Use in Patient Care

In the Access Hospital Dayton fraud case, the psychiatric hospital and its owner agreed to pay $425,000 to resolve allegations of unnecessary inpatient laboratory testing billed to Medicare and Ohio Medicaid. The allegations covered testing from January 2014 through December 2019.

The government said the prolactin and ammonia tests were not used to manage patients’ conditions. It also explained that both programs generally prohibit separate payment for diagnostic testing during an inpatient admission.

Access Hospital Dayton LLC and its physician owner agreed to pay the United States $374,780 and Ohio approximately $50,219. The Department of Justice announced the resolution on November 3, 2021. The federal agreement resolved False Claims Act allegations, while the Ohio agreement resolved state Medicaid claims.

The Prolactin and Ammonia Testing Allegations

The government alleged that Access and its owner knowingly caused false claims for prolactin and ammonia testing during patients’ inpatient stays. It described the tests as medically unnecessary and unused in managing the patients’ conditions. The allegation connected the laboratory bill to the care of the particular patient the testing supposedly served.

The tests have specific diagnostic purposes. In its announcement, the Department of Justice described prolactin testing as measuring prolactin in the blood to help diagnose pituitary tumors or determine causes of conditions unrelated to psychosis or substance abuse. It described ammonia testing as a way to diagnose liver dysfunction or hyperammonemia.

For a hospital insider, the clinical purpose is a concrete question. What condition was the physician investigating, and how did the result inform management of that condition? The government’s allegation reached the second part: the testing did not serve the patients’ medical management.

We see the absurdity in that allegation. Public health care programs were being billed for diagnostic information that, according to the government, never informed the patients’ care. A result for the bill. No use for the patient.

Why the Inpatient Admission Mattered

The inpatient setting added a separate payment issue. The Justice Department explained in its announcement that Medicare and Ohio Medicaid generally prohibit separate payment for diagnostic testing performed during an inpatient admission. It also said Medicare pays for diagnostic testing ordered by the physician who uses the results to manage the beneficiary’s specific medical problem.

That puts the patient’s care and the billing arrangement in the same picture. The medical-use question concerns why the test was ordered and what the physician did with its result. The payment question concerns the separate diagnostic claim submitted while the patient was already admitted. An insider may recognize either part through ordinary clinical or billing work.

The wider inpatient psychiatric payment structure helps explain the connection. Medicare’s inpatient psychiatric facility payment system uses a daily payment adjusted for patient and facility characteristics. Psychiatric hospitals must have an individualized treatment plan for each patient.

The treatment plan gives the laboratory work a clinical context: the patient’s condition, the reason for diagnostic study and the care being provided. In the Access allegations, the question was where the prolactin and ammonia testing fit into that care. The government said it did not.

Acadia and Unused Test Results

A whistleblower complaint against Acadia Healthcare Company raised a similar concern about unused test results, alleging that clinicians commonly failed to evaluate or document blood and urine laboratory results even when specimens were collected.

What Hospital and Laboratory Insiders Can See

An insider’s knowledge can connect the reason for a test with the way it was billed. A clinician may know whether a result was reviewed or used in the treatment plan. A laboratory worker may know whether a specimen was collected and a test performed. A billing employee may know which provider submitted the claim and whether it fell during an inpatient admission.

We work with insiders to connect what they know about the clinical work to the claims and the decisions behind them. If you recognize that split between healthcare delivered and healthcare billed, you have a specific starting point for a conversation with our whistleblower experts.

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

You Know Where the Lab Work Went

If you saw tests ordered and billed without a place in patients’ care, talk with our whistleblower experts about what happened inside the hospital. We build the case with you, bring in whistleblower lawyers who understand psychiatric-hospital and laboratory billing, and stay beside you through the pursuit of a recovery.