Uncovering improper billing in urine drug screens

Improper billing practices and schemes associated to urine drug screens (UDS) are widespread, requiring investigative sources to detect potential fraud, waste, and abuse (FWA). Although the Facilities for Medicare & Medicaid Companies (CMS) regulates human lab samples by way of strict tips outlined within the required Medical Laboratory Enhancements Amendments (CLIA) certification, some laboratories and testing amenities could lack up-to-date certifications, posing a threat to members and payers alike.

As demonstrated in a single current investigation performed by Cotiviti’s particular investigations unit (SIU), with meticulous medical evaluation and information mining, Health plans can safeguard member care and assist cut back improper billing.

Random sampling of medical data reveals systematic discrepancies

The investigation started when a nurse practitioner (NP) affiliated with an inner medication follow specializing in dependancy and substance abuse problems was flagged for extreme billing of UDS. By means of a statistically legitimate random sampling of medical data using CPT code 80307 and HCPCS code G0481, information confirmed that the NP had been billing for each presumptive and definitive UDS on the identical date of service—a follow that violates customary procedural norms.

Further investigation revealed that the practitioner was related to a follow whose doctor proprietor had their license suspended for public Health code violations in 2022. The investigation additionally uncovered the usage of place of service code 81, indicating unbiased laboratory testing, which didn’t align with the NP’s position or licensed capabilities.

Cotiviti’s SIU employed a multi-pronged strategy to find out the prevalence of FWA. Looking for the required CLIA certification revealed that the NP and follow weren’t approved for lab testing, with superior information evaluation uncovering the NP because the second-highest paid supplier for UDS codes, surpassing even main business labs. Further purple flags included claims submitted with the NP as each the rendering supplier and affected person and an “inconceivable day” situation whereby claims had been submitted for as many as 66 distinctive sufferers on the identical date of service.

By making use of a multi-faceted evaluation to verify discrepancies and improper billing practices, we recognized greater than $1.1 million in overpayments made to the supplier whereas the consumer positioned the follow on prepay evaluation to mitigate future inappropriate billing.

Key takeaways for Health plans

Latest developments in UDS billing characterize an space of concern for potential FWA. Health plans can mitigate the danger of paying inappropriate claims by way of a multi-faceted strategy utilizing these greatest practices:

• Guarantee a legitimate CLIA certificates was maintained through the timeframe recognized for the audit. CLIA certificates are legitimate for 2 years and have to be renewed by the supplier or group.
• Search for suppliers who’re outliers for lab testing codes when information mining to make sure testing is carried out by the suitable particular person as set forth by CMS and CLIA rules. Flag inconceivable day situations for testing carried out on extra sufferers than attainable in a single day based mostly on lab dimension, variety of certified personnel, sort of kit, or testing billed on weekends and holidays.
• Knowledge mine for suppliers billing each presumptive and definitive UDS on the identical dates of service. It is a purple flag, as not all UDS require a definitive take a look at. The definitive take a look at ought to solely be carried out when there’s a constructive outcome on the presumptive take a look at and the definitive testing is ordered by the referring doctor. Additionally search for labs billing just one code within the code sequence for all sufferers. Because the definitive take a look at depends upon the outcomes of the presumptive take a look at and must be tailor-made to the affected person’s particular medical wants, IT is uncommon for a supplier to check the identical variety of drug lessons for each affected person.