Preferred Pain Management: Both Tests, Every Patient, Every Month

The Preferred Pain Management settlement called for a $789,293 payment from the practice and its owner over alleged unnecessary urine drug testing and separate specimen-validity bills. The government alleged that every patient’s monthly visit generated both presumptive and definitive tests, without an individual decision about need or risk. The alleged routine treated the appointment calendar as the reason to test, and sent the bills to taxpayers.

Preferred Pain Management & Spine Care, P.A. was the Winston-Salem, North Carolina practice named in the Justice Department’s April 16, 2021 announcement. The civil settlement resolved False Claims Act allegations involving bills to Medicare, Medicaid and other federal health care programs. The government placed the allegedly unnecessary testing between June 1, 2014 and May 24, 2017.

Both Urine Drug Tests at Every Monthly Visit

Preferred Pain Management allegedly made presumptive and definitive urine drug testing automatic for all patients at their monthly visits. The government said the practice and its owner ordered both without determining each patient’s need or risk profile. The same pair of tests followed the appointment schedule across the practice.

The Justice Department described presumptive testing as screening for the presence of drugs, and definitive testing as identifying their concentration in the patient’s system. The allegation concerned the missing individual judgment behind those decisions.

A 2021 Journal of Family Practice review describes immunoassay as a rapid, relatively inexpensive screen and liquid chromatography-mass spectrometry as a more specific, costlier confirmation.

That review connects the choice of method to the clinical question, how urgently the result is needed and what decision will follow. In the government’s account of Preferred Pain Management, the monthly routine supplied the answer in advance.

When Are Toxicology Tests Unnecessary?

In this case, the government alleged that toxicology tests were unnecessary because no one decided, patient by patient, that they were needed. The practice allegedly knowingly submitted, or caused the submission of, claims for presumptive and definitive tests that were not medically reasonable or necessary. The automatic monthly orders were how the government described that conduct.

Pain medicine gives the testing a purpose. A 2014 Pain Physician paper describes urine testing used to monitor adherence to prescribed medication, identify nonprescribed drug use and support therapeutic monitoring. It also describes unexpected results prompting a discussion with the patient about continuing care.

The Journal of Family Practice review ties testing frequency to ongoing assessment, including prior toxicology results, patient reports, behavior and prescription-monitoring information. It describes different frequencies for different risk levels. That gives an insider something more concrete than a general demand for medical necessity: the reason for the next test should come from what is known about that patient.

The paperwork sits in different hands. Under Medicare’s ordering and documentation requirements, the treating practitioner maintains the medical-necessity documentation in the patient’s record. The entity billing for the test maintains the information it received and documentation that the claim reflects it accurately. A laboratory employee may see an order and a result while the reason for the order sits in the practice’s chart. Our whistleblower experts evaluate what the order, the chart and the claim show about the testing decisions in a healthcare whistleblower case.

Can Specimen Validity Testing Be Billed Separately?

Specimen validity testing performed as quality control with urine drug testing is not separately payable by Medicare. In the Preferred Pain Management announcement, the Justice Department said Medicare’s guidance had made that explicit since January 2014. The government alleged that the practice nevertheless billed Medicare separately for specimen-validity testing throughout 2014 and 2015.

The monthly double-testing allegation concerned the reason for ordering the tests. The validity allegation concerned charging Medicare separately for the quality-control work accompanying them.

According to the government, Preferred Pain Management sought that payment after Medicare had explicitly said the service should not be billed separately. The alleged result: taxpayers faced an additional bill for quality control already included with the drug-testing service.

The Civil Settlement and the Whistleblower’s Share

The whistleblower’s qui tam case brought the monthly-testing allegations, while the government separately identified the allegedly improper specimen-validity billing. The Justice Department said the whistleblower would receive a share of the federal recovery, excluding recovery for that validity billing.

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

Standing Orders for Urine Drug Tests: The Pattern Insiders See

An insider familiar with the billing may know how specimen-validity work became a separate Medicare claim.

The settlement announcement also credits HHS-OIG auditors with identifying suspicious billing through forensic tools. An insider can explain the routine that produced it: who made the testing automatic, where the patient-specific decision should have occurred and how the quality-control work reached the claim.

A similar ordering problem appeared in Precision Toxicology. In its October 2, 2024 settlement announcement, the Justice Department alleged that the laboratory promoted custom profiles that functioned as standing orders, producing large numbers of urine drug tests without an individualized assessment of each patient’s needs.

Preferred Pain Management’s alleged routine was tied to the monthly visit. Precision’s alleged routine used custom profiles. Both accounts put the individual ordering decision at the center of the case. An insider who knows how that decision disappeared can explain something a paid claim alone cannot: how the business made the next test automatic.

You Know How the Monthly Orders Worked

If you saw both tests ordered before anyone considered the patient, or specimen checks turned into separate bills, tell our whistleblower experts what happened inside the practice. We work with you to build your strongest laboratory fraud whistleblower case around the ordering decisions and charges, bring in laboratory fraud whistleblower lawyers who understand pain-practice testing, and stay with you throughout the case.