Comprehensive Pain and Headache Treatment Centers: What the Urine Testing Bill Has to Show

Comprehensive Pain and Headache Treatment Centers and its owner agreed to pay $427,691 in a July 2019 civil settlement over urine-testing claims to Medicare and Connecticut Medicaid. The practice operated in Derby and Meriden, Connecticut. The settlement covered conduct from May 15, 2013, through December 31, 2015.

Tests Not Performed and Components Billed Again

The government alleged two billing problems. The practice submitted claims for quantitative urine testing that it had not performed. It also billed separately for alcohol and amphetamine/methamphetamine tests that were already components of paid urine screening tests.

The announcement distinguishes screening for the presence of a drug from quantitative testing that reports its concentration. The allegations concerned both what the practice actually performed and what the paid screening service already included. Those are separate comparisons for a laboratory or billing employee who knows how the claim was produced.

How Should Laboratory Tests Be Bundled for Medicare?

Laboratory panel billing has to account for the work covered by the panel. A panel groups tests under a single billing code. The financial issue is whether separate component claims make the government pay more for work already covered by that service.

The General Accounting Office explained the economics in its 1998 report on hospital laboratory billing. Automated equipment could perform multiple tests on a blood sample together, reducing labor and handling costs. A profile generally paid less than the same tests billed individually. The report described the resulting overpayment when tests performed as a profile were submitted and paid separately.

For an insider, the connection runs from the panel’s contents to the claim lines. We examine what each paid service included and whether a component generated another charge for that same work. The panel definition matters as much as the description on the extra line. The question is what additional service the government was being asked to buy. When Medicare pays again for work already covered, taxpayers fund the extra charge without buying additional health care.

When Are Toxicology Tests Unnecessary?

Toxicology testing can be unnecessary when its frequency or scope goes beyond the patient’s clinical need. The Journal of Family Practice review ties testing frequency to ongoing assessment, including earlier results and the patient’s circumstances. Testing at every visit can generate bills for work a stable patient does not need:

The same review describes the financial incentive to use large, expensive panels, test too frequently or send positive screens for unnecessary confirmatory analysis. Those choices sit upstream of the bill. By the time a claim arrives, the choice of tests and frequency has already shaped what the laboratory can charge.

We examine the ordering decision alongside the result and the claim. A practice’s test-selection policy and a patient’s clinical record answer different parts of that question: what the routine called for, and why this patient needed this test.

What Evidence Is Needed to Prove Fraud?

The evidence lies in the gap between the testing a practice performed and the service it billed. We build that account with you, connecting the clinical and laboratory records to the paid claims and the decisions behind them.

The documentation is divided between the clinical and billing sides. Under Medicare’s laboratory documentation requirements, the ordering practitioner maintains the medical justification in the patient’s record. The billing provider keeps what the practitioner sent and proof that its claim matches that information. That division explains why a billing employee and a clinician may each know something the other cannot see.

The performing laboratory matters too. Laboratories send out work that requires equipment, expertise or a volume of testing they do not have in house. A review therefore follows the specimen through the work performed and the result returned, as well as the bill.

In a separate case, Sutter Health agreed to a $13,091,452 settlement over allegations of billing for toxicology screening tests performed by others, according to the Justice Department’s October 17, 2022 announcement. That example puts the identity of the performing laboratory at the center of the billing question. A component-billing inquiry instead compares the claimed component with the work already included in the paid service.

A laboratory employee may understand the method and the result. A clinician may know why the test was ordered. A billing specialist may recognize how the panel became separate claim lines. We bring those accounts together around the same services and payments.

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

You Know How the Test Became a Bill

If you know the testing method, the panel contents or the decision behind an extra claim, speak to one of our Whistleblower Experts about the testing you saw. We work with you to build your strongest laboratory whistleblower case and bring in healthcare fraud whistleblower lawyers who understand toxicology claims. We stay beside you through the case, connecting what happened in the laboratory to the decisions behind the bills.