Huntsville Physician Urine Drug Testing Fraud: Tests That Dominated Claims but Did Not Guide Treatment

A Huntsville pain physician’s urine drug testing drew $9.5 million in reimbursements for tests prosecutors alleged he did not need or use in treatment. He operated Chronic Pain Care Services in Huntsville, Alabama. The criminal charges described a clinic where insurance coverage determined the testing method, standing orders kept the machines busy, and prescriptions often reached patients before their initial screens ran. The charges alleged that tests generated claims even when their results played no part in care.

According to the Justice Department’s September 23, 2016 announcement, urine drug tests accounted for about 80% of the paid claims he submitted to Medicare and Blue Cross Blue Shield of Alabama between January 2011 and March 2013. Testing had become the dominant claim category in a practice ostensibly treating pain.

The government set out the testing scheme in a criminal information filed in federal court. According to the Justice Department’s account of his filed plea agreement, the physician’s primary motive for testing urine and submitting claims was financial gain.

When Are Toxicology Tests Unnecessary?

Toxicology tests are unnecessary when they lack a patient-specific diagnostic or treatment purpose. In the Huntsville criminal information, prosecutors alleged that the physician chose tests according to how much he could bill, then failed to use their results in treatment. The accusation reached both ends of the process: why the test was ordered and what happened after the result came back.

Urine drug testing has a concrete role in pain care. The 2014 Pain Physician paper Ethical Perspectives on Urine Drug Screening for Pain Physicians describes its use to monitor whether patients take prescribed medication and whether they use illicit drugs.

The paper says a practice must not ignore test results and keep prescribing opioids without a formal plan.

The 2021 Journal of Family Practice review Urine Drug Screening: A Guide to Monitoring Tx With Controlled Substances likewise recommends choosing the test and its frequency around patient risk. It describes excessive testing for profit as a misuse of the tool.

Insurance Chose the Test

The criminal information alleged that insured patients received two expensive automated urine tests at every appointment, while uninsured patients received a cheaper dipstick-style test. Both automated tests used an immunoassay method on chemistry analyzers at the clinic. The uninsured patients’ point-of-care tests also used an immunoassay method.

Prosecutors described a rigid division. Insured patients could not choose the cheaper test, and uninsured patients could not choose the analyzer tests. The filing attributed that division to the amount the doctor could bill, rather than the particulars of a patient’s treatment.

Its account of the payments shows the incentive. During the charged period, the doctor sometimes billed Medicare up to approximately $400 for the first automated test and received up to approximately $200. For the second automated test, he sometimes billed Medicare up to approximately $600 and received up to approximately $300. Medicare and Blue Cross reimbursement for a point-of-care test was approximately $20. The choice of testing method changed the money attached to the specimen.

Prosecutors alleged that staff ran the second, supposedly more precise test even when the first showed the drug was absent. Patient history, earlier results and individual need did not determine that second test, according to the filing. Where the second test gave more precise results, prosecutors said the first was unnecessary for treatment.

The Machines Changed the Testing Schedule

According to the criminal information, the physician changed the frequency of testing after acquiring the equipment that let him bill directly for higher-paying tests. Before that, testing had been randomized. After purchasing chemistry analyzers in 2011, he began testing insured patients at every scheduled visit and at certain prescription refill pickups. The filing explained that randomized testing gave patients less advance notice to falsify results. Scheduled testing gave up that advantage while creating another occasion to bill.

The alleged standing order carried the decision into the clinic’s daily work. Staff were instructed to run insured patients’ specimens through both analyzer tests regardless of their medical history or need. A patient arriving for an appointment supplied another specimen for the same testing routine. The order had already been made.

That connection is useful to an insider who saw an equipment purchase followed by a new testing instruction. The relevant history includes who made the order automatic and whether the patient’s circumstances still had any influence on what ran.

The Prescription Came Before the Result

The criminal information alleged that initial urine screens for insured patients often ran after the doctor had already given them their prescriptions. A screen intended to inform the prescribing decision was arriving after that decision.

Result review was also part of the allegation. Prosecutors said the doctor delegated review to an unlicensed, untrained staff member and instructed that person to initial results using the doctor’s initials. A mark suggesting physician review could therefore conceal who had actually looked at the result.

The filing described abnormal results that the doctor often ignored: illicit or non-prescribed drugs present, or prescribed drugs absent. It alleged that patients with repeated results showing illegal drugs were not referred for counseling or addiction treatment, and that some received increased doses.

The clinic’s pace puts those allegations in context. The criminal documents described about 80 to 145 patients visiting the office each day in 2012. Initial visits typically lasted five minutes or less, and follow-ups two minutes or less. Prosecutors alleged that follow-up visits included no physical examination and no testing other than urine drug testing. In that account, the test remained a recurring service to bill while the treatment decision received little time and often no benefit from its result.

The Order and the Claim Came From the Same Practice

The criminal information described a physician who controlled the clinical orders and submitted the testing claims. That brought together decisions often separated in the laboratory business. An independent laboratory generally depends on an outside clinician to order testing and maintain the medical record explaining its necessity. A physician’s office can combine the treatment, the laboratory equipment and the claim inside one practice.

The criminal information described the payment promises attached to those claims. Medicare required reasonable and medically necessary services. Under the physician’s agreement with Blue Cross Blue Shield of Alabama, laboratory services had to be appropriate and necessary for the patient’s condition and provided for diagnosis or direct care and treatment. The doctor also agreed to treat Blue Cross members according to the same standards as other patients.

Those promises make the alleged split by insurance status especially revealing. The payer relationship called for testing tied to care. Prosecutors said the clinic used that relationship to decide which patients received the more expensive testing routine.

For a clinic employee, laboratory worker or billing specialist, that is a recognizable healthcare fraud concern. The instruction given to staff, the tests performed, the review initials and the claim can each show a different part of the same transaction. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Saw What Happened After the Test

If you worked with automatic urine-testing orders or results that never reached the treatment decision, speak with our whistleblower experts about what happened inside the practice. We build the case with you and bring in laboratory fraud whistleblower lawyers who understand the connection between clinical necessity and billing. We stay beside you as your knowledge of the clinic becomes a case for recovering public money.