Avoiding New OIG Litigation

[Aether2000]

The OIG is using their enforcement tools to entrap doctors and stop their submission of claims for Medicare/Medicaid. This has a subsequent effect of affecting contracts with insurance companies, hospital privileges, and medical licensure. The article below recounts the outcome of a recent sweep. This action by the OIG was particularly troublesome for pain physicians since it targeted:
1. Injections that were thought by the OIG to be fraudulent
2. Opioid medications that were overprescribed therefore costing Medicare excessive money therefore was fraudulent
3. Excessive urine drug screenings resulting in billing of Medicare considered to be fraudulent
4. Kickback schemes by doctors involved with "compounding pharmacies" who were given cash back for referrals to specific pharmacies or were part owner of these pharmacies.

Be careful- ditch any compounding pharmacy relationship you have that results in direct payments to you or your company (and consider sending back any such monies collected). Also make sure you justify all injections with a note that supports the medical necessity for the injection. Templated notes may be created directly from Medicare policies on injections. Reduce the prescribing of opioids. Make sure your urine drug screen policy is reasonable- e.g. random and not every visit, avoid the full panel LC/MS confirmation screens billed for over a thousand dollars, etc.

Nationwide Medical Fraud Sweep Nets Dozens of Docs, Nurses
Charges range from fraudulent opioid prescribing to kickback scheme

• John Gever, Managing Editor, MedPage TodayJuly 13, 2017

More than a hundred healthcare professionals including physicians and nurses were charged with crimes Thursday in a nationwide fraud sweep involving federal and state law enforcement, the Office of the Inspector General (OIG) in the Department of Health and Human Services announced.

Among a total of 412 people charged were 115 healthcare professionals, according to OIG. In addition, 295 individuals are now barred from submitting reimbursement claims to federal health programs including Medicare and Medicaid "for conduct related to opioid diversion and abuse." The exclusion notices were served on 57 physicians, 162 nurses, and 36 pharmacists.The criminal charges covered a wide range of alleged fraud. The OIG announcement mentioned one physician in Texas charged with overprescribing opioids and then fraudulently billing Medicare for $1.2 million. OIG also highlighted a Michigan group including five physicians "who allegedly engaged in illegal kickbacks and billing for medically unnecessary joint injections, drug screenings, and home health services." This group took $126 million in Medicare payments, according to OIG.

In all, the 412 criminal defendants were charged in 41 federal districts and the allegedly fraudulent billings totaled more than $1.3 billion. OIG called the sweep the largest multi-agency enforcement operation in history, "both in terms of the number of defendants charged and loss amount."

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[deleted185747]

A savvy businessman lines his own pockets and keeps business within his network/self referral. We (providers) aren't allowed to be savvy businessmen.

 

[ateria radicularis magna]

The OIG is using their enforcement tools to entrap doctors and stop their submission of claims for Medicare/Medicaid. This has a subsequent effect of affecting contracts with insurance companies, hospital privileges, and medical licensure. The article below recounts the outcome of a recent sweep. This action by the OIG was particularly troublesome for pain physicians since it targeted:
1. Injections that were thought by the OIG to be fraudulent
2. Opioid medications that were overprescribed therefore costing Medicare excessive money therefore was fraudulent
3. Excessive urine drug screenings resulting in billing of Medicare considered to be fraudulent
4. Kickback schemes by doctors involved with "compounding pharmacies" who were given cash back for referrals to specific pharmacies or were part owner of these pharmacies.

Be careful- ditch any compounding pharmacy relationship you have that results in direct payments to you or your company (and consider sending back any such monies collected). Also make sure you justify all injections with a note that supports the medical necessity for the injection. Templated notes may be created directly from Medicare policies on injections. Reduce the prescribing of opioids. Make sure your urine drug screen policy is reasonable- e.g. random and not every visit, avoid the full panel LC/MS confirmation screens billed for over a thousand dollars, etc.

Nationwide Medical Fraud Sweep Nets Dozens of Docs, Nurses
Charges range from fraudulent opioid prescribing to kickback scheme

• John Gever, Managing Editor, MedPage TodayJuly 13, 2017

More than a hundred healthcare professionals including physicians and nurses were charged with crimes Thursday in a nationwide fraud sweep involving federal and state law enforcement, the Office of the Inspector General (OIG) in the Department of Health and Human Services announced.

Among a total of 412 people charged were 115 healthcare professionals, according to OIG. In addition, 295 individuals are now barred from submitting reimbursement claims to federal health programs including Medicare and Medicaid "for conduct related to opioid diversion and abuse." The exclusion notices were served on 57 physicians, 162 nurses, and 36 pharmacists.The criminal charges covered a wide range of alleged fraud. The OIG announcement mentioned one physician in Texas charged with overprescribing opioids and then fraudulently billing Medicare for $1.2 million. OIG also highlighted a Michigan group including five physicians "who allegedly engaged in illegal kickbacks and billing for medically unnecessary joint injections, drug screenings, and home health services." This group took $126 million in Medicare payments, according to OIG.

In all, the 412 criminal defendants were charged in 41 federal districts and the allegedly fraudulent billings totaled more than $1.3 billion. OIG called the sweep the largest multi-agency enforcement operation in history, "both in terms of the number of defendants charged and loss amount."

Regarding full panel with confirmation...one thing I don't understand is how a basic screen, with a huge probability of false positive, could be useful in any sense.

 

[Aether2000]

A full panel confirmation would be confirmation of the entire array of positive and negative findings, a series of tests costing from $900-1800. A much more reasonable approach would be to select those tests per patient that were in question and only run confirmations on one or two questionable drugs, including fentanyl since that is not detectable on UDS. This can cut the cost to $100-200. The lack of random drug screens (i.e. every month drug screens were being performed) and the presence of a confirmatory spectrophotometric machine in the office and owned by the doctor appeared to trigger OIG scrutiny.

 

[drpainfree]

A full panel confirmation would be confirmation of the entire array of positive and negative findings, a series of tests costing from $900-1800. A much more reasonable approach would be to select those tests per patient that were in question and only run confirmations on one or two questionable drugs, including fentanyl since that is not detectable on UDS. This can cut the cost to $100-200. The lack of random drug screens (i.e. every month drug screens were being performed) and the presence of a confirmatory spectrophotometric machine in the office and owned by the doctor appeared to trigger OIG scrutiny.

I don't own a UDS lab and am pretty "random" when it comes to doing UDS. On the other hand, I'm wondering how you decide on "questionable drugs" to do quantitative on.

Let's say qualitative POC cup testing shows negative for everything except hydrocondone and its metabolite. Do you run confirmation on a few? Don't you want to run everything else to make sure the patient is not using benzo, alcohol, etc?

 

[Aether2000]

It is a judgment call. Alcohol is not typically detected on UDS but the metabolite may be detected on LC/MS. Heroin shows up as morphine on UDS for 1-2 days after use because the drug is metabolized within a few minutes to morphine. Heroin itself is almost never detectable in UDS or LC/MS but the metabolite 6-MAM may be detected on LC/MS for up to 8 hours after use. Fentanyl is now being used as a drug to lace heroin and would not show up on UDS. Benzos are difficult to interpret given the chain of metabolites that are active prescription drugs and the detection of multiple metabolites are necessary in some cases to determine which one(s) are being taken by the patient. The bottom line is what will be done with the information? If the office policy is to stop opioids if these drugs are detected then it may be worth obtaining these tests. If the office policy is simply counseling, then it may not be worth doing the testing since the patient will most likely continue to use these drugs. Even more damaging in cases of state medical board actions and possibly OIG is obtaining these tests but failing to act on them at all.

 

[drpainfree]

It is a judgment call. Alcohol is not typically detected on UDS but the metabolite may be detected on LC/MS. Heroin shows up as morphine on UDS for 1-2 days after use because the drug is metabolized within a few minutes to morphine. Heroin itself is almost never detectable in UDS or LC/MS but the metabolite 6-MAM may be detected on LC/MS for up to 8 hours after use. Fentanyl is now being used as a drug to lace heroin and would not show up on UDS. Benzos are difficult to interpret given the chain of metabolites that are active prescription drugs and the detection of multiple metabolites are necessary in some cases to determine which one(s) are being taken by the patient. The bottom line is what will be done with the information? If the office policy is to stop opioids if these drugs are detected then it may be worth obtaining these tests. If the office policy is simply counseling, then it may not be worth doing the testing since the patient will most likely continue to use these drugs. Even more damaging in cases of state medical board actions and possibly OIG is obtaining these tests but failing to act on them at all.

in my practice, yes, d/c opioids if aberrant behavior/findings are discovered. So I do confirmation non-selectively.

 

[emd123]

I dont do any more in office dipsticks. I think they're almost worthless. I do a send out LC/MS on new opiate patients, and about twice a year, unless questions of aberrancy. I think that's completely reasonable and complies with state/fed regs, yet doesn't exceed them. Plus they're all send outs. I make $0 profit off them so for the feds to accuse me of fraud for ordering a test they're requiring me to do and I make no fraudulent or financial motivation to overrode it not likely to be prosecutable. What they will go after, are the pee mills, that drug test every visit in their own in office lab to pay for the doc to have a Ferrari in the driveway. They'll go after that, since they could prove a financial motivation to over order the tests and can quantify the profits you've received from it.

But for the doc driving the Toyota, who wants to have a decent drug test sent out once or twice year, that's required and actually accurate, is not only reasonable, but necessary for proper and safe patient care and monitoring, and easily justifiable to a medical board, or jury. The false negatives and positives of in office dipsticks, although cheaper, aren't doing anyone any favors.

 

[Yo GabbaPentin]

I dont do any more in office dipsticks. I think they're almost worthless. I do a send out LC/MS on new opiate patients, and about twice a year, unless questions of aberrancy. I think that's completely reasonable and complies with state/fed regs, yet doesn't exceed them. Plus they're all send outs. I make $0 profit off them so for the feds to accuse me of fraud for ordering a test they're requiring me to do and I make no fraudulent or financial motivation to overrode it not likely to be prosecutable. What they will go after, are the pee mills, that drug test every visit in their own in office lab to pay for the doc to have a Ferrari in the driveway. They'll go after that, since they could prove a financial motivation to over order the tests and can quantify the profits you've received from it.

But for the doc driving the Toyota, who wants to have a decent drug test sent out once or twice year, that's required and actually accurate, is not only reasonable, but necessary for proper and safe patient care and monitoring, and easily justifiable to a medical board, or jury. The false negatives and positives of in office dipsticks, although cheaper, aren't doing anyone any favors.

Exactly how I do it as well. And I even drive a Toyota.