Coastal Spine and Pain: A Second Test With Every Screen

Coastal Spine and Pain, the trade name of Physicians Group Services, agreed to pay $7.4 million in a settlement over allegedly unnecessary quantitative urine drug testing. The government said the practice billed for the more expensive test every time it billed for the initial screen, regardless of what that screen showed. If you worked with those orders or claims, the question is concrete: did the patient’s result ever change the decision to run the next test?

The Justice Department announced that resolution in 2016. In 2022, Physicians Group Services, a Jacksonville, Florida provider, reached a separate settlement over claims to Florida Medicaid. We see these successive settlements involving one practice circling the same basic question: why did this patient need the additional test?

The Test After the Test

The 2016 Coastal Spine and Pain settlement concerned an alleged pattern of performing quantitative urine tests regardless of the results of qualitative screens. The government’s account describes qualitative testing as the more general, less expensive screen. Quantitative tests identify and count drug particles in urine, providing more specific information at greater expense.

According to the announcement, quantitative testing was appropriate when there was reason to doubt the initial screen. The government alleged that Coastal performed and billed for it for all patients anyway, even when there was no reason to question or further confirm the earlier result. We see the problem in that alleged arrangement: a test intended to answer a clinical question became another bill whether the question existed or not.

That makes the first test’s result central to the medical necessity allegation. The government described an additional test whose justification depended on what was already known about the patient. An insider familiar with the initial result and the decision to order more testing can connect the clinical reason to the claim.

Claims Data Exposed the Pairing

Proactive review of claims data prompted the 2016 investigation. The Justice Department said Coastal stood out statistically because every billed qualitative screen came with a billed quantitative screen. The recurring pair prompted questioning and investigation. Claims show which services a practice’s healthcare billing paired together, while patient records and the people making the orders can explain why.

The announcement named Medicare, TRICARE and other federal health care programs among the programs the U.S. Attorney’s Office sought to protect. The U.S. Attorney’s Office for the Middle District of Florida handled the case, with investigative assistance from the Department of Health and Human Services Office of Inspector General and the Defense Criminal Investigative Service.

Florida Medicaid and the Patient’s Own Needs

The 2022 Physicians Group Services settlement resolved allegations of medically unnecessary quantitative urine testing billed to Florida Medicaid. The United States and Florida alleged that the testing was not individualized to the patient’s particular needs.

Urine drug testing in a pain practice can monitor whether a patient takes prescribed medication, takes non-prescribed drugs or consumes other dangerous substances, such as alcohol, alongside prescribed drugs. The announcement explains why the patient’s circumstances matter to the next test. The clinical value of quantitative testing depends partly on whether the first result is expected or unexpected, the patient’s history of drug abuse and medication adherence, the patient’s clinical presentation and medical history. We would want to understand how the initial result and the patient’s history entered the ordering decision, and how that decision reached the Medicaid claim.

The U.S. Attorney’s Office for the Middle District of Florida led the civil investigation. The Department of Health and Human Services Office of Inspector General and the Florida Attorney General’s Medicaid Fraud Control Unit joined the coordinated effort.

What Evidence Does a Whistleblower Need?

For unnecessary urine-testing allegations, useful evidence connects the test orders, results and patient history to the submitted claims. You may know who ordered the test, whether the initial result was reviewed, or how the reason for more testing was recorded. We work with you to connect the part you saw to the ordering and billing decisions, including who directed them.

The 2017 Journal of AHIMA article Busting Bad Medicine: a Call to Action Addressing Healthcare, Fraud, Waste, and Abuse connects billing review to treatment dates, treatment types and clinician signatures. It also explains why written records and firsthand knowledge belong together:

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. Our work with a practice insider is to connect what they know about the tests, the bills and the people directing them to the government money at stake.

Other Pain-Practice Cases Follow the Order and the Bill

In a separate civil settlement, National Spine and Pain Centers and Physical Medicine Associates resolved allegations involving unnecessary urine drug testing, testing claims tied to prohibited referrals, and nurse-practitioner and physician-assistant services billed as physician services. A former physician assistant brought that whistleblower case. Who performed the care and whose name appeared on the claim were part of the alleged billing mismatch.

The government’s complaint announcement about Comprehensive Pain Specialists described alleged standing-order testing and required referrals to an owned laboratory. The practice’s later civil resolution included allegations of unnecessary or nonreimbursable urine tests and use of a physician’s provider number for care he did not render and tests he did not order. Across these separate cases, the ordering policy and the identity on the claim give an insider concrete decisions to explain.

You Know How the Next Test Was Ordered

If you saw urine tests ordered regardless of the patient’s results or history, speak with our whistleblower experts about the claims behind those orders. We work alongside you to build your strongest whistleblower case and bring in physician billing fraud whistleblower lawyers who understand testing and medical necessity.