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DOJ Catch Of The Week -- Coastal Spine And Pain

Posted  September 2, 2016

By the C|C Whistleblower Lawyer Team

This week’s Department of Justice “Catch of the Week” goes to Jacksonville-based Physicians Group Services, P.A., doing business as Coastal Spine and Pain.  On Wednesday, the surgery and pain-management clinic agreed to pay $7.4 million to settle charges it violated the False Claims Act by performing medically unnecessary drug screening procedures.  See DOJ Press Release.

The settlement relates to Coastal’s use of Quantitative Drug Tests, which are tests designed to identify illicit drugs in patients’ urine.  These tests are very specific and very expensive and thus only supposed to be used if there is reason to question the more general and less expensive qualitative drug test screens.  But according to the government, Coastal routinely used these more expensive, higher precision tests regardless of the results of the primary qualitative tests.

As the Florida Times Union reported, the unnecessary drug testing included expensive screening of elderly patients for drugs such as ecstasy, cocaine and heroin.  The clinic would apparently test 80-year-olds for exotic and illegal drugs, first with a test to detect the presence of those and other more common drugs and then, even when no evidence was found, with a much costlier screen that would detect the exact quantities of those drugs in the person’s system.  As the government described it, every patient was tested every time for every drug.  “Even if the results were negative, they ran this very sophisticated, very expensive test to confirm that the tests were negative.”

What makes this case particularly notable is that the government uncovered the wrongdoing through its proactive review of claims data.  The government found that Coastal was a statistical outlier in terms of billing for quantitative drug test screens, and that every time it billed for a qualitative drug test screen, it also billed for a quantitative drug test screen.  This pattern prompted questioning and investigation by the Department of Justice.

The government pointed to its use of this kind of data to warn other companies that may be engaging in similar patterns of Medicare fraud.  Shimon Richmond of the Health and Human Services Department Office of the Inspector General noted that this “new and expanded use of data analytics to identify suspicious billing patterns . . . are providing law enforcement agencies with powerful investigative tools to combat fraud and abuse in federal health care programs.”  He added that “Medicare should only be paying for medical tests to improve the health of beneficiaries, not the profit margins of unscrupulous physicians,” and that the settlement “should serve as notice to others that fraud will be vigorously pursued.”

Tagged in: Catch of the Week, FCA Federal, Lack of Medical Necessity, Medicare,