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The field of pain medicine is rife with scams of patients, unethical behavior, and substandard care. I am writing an article to warn patients of these behaviors and invite your contributions to this preliminary list that is undoubtedly controversial.
1. Frequent urine drug screens with confirmation using an in-house analyzer. Urine drug screens may be performed using a dip stick cup costing between $5 and $10. However due to errors in some of the results and the lack of quantitation, doctors began sending in urine specimens to confirmation laboratories. These labs would charge up to $2000 for a confirmation analysis, and with insurance companies balking at paying such high rates, the patients were left paying the balance over months to years. Pain physicians quickly realized by purchasing a $30,000-$200,000 machine to do the same thing, they could capture all this lost revenue previously being paid by patients and insurance to external diagnostic laboratories. However, the amount of testing increased significantly after physicians acquired their own in-house analyzers. Instead of occasionally testing patients, the tests could be as frequent as every office visit with charges to the insurers for many unnecessary tests. Of course if a patient has an aberrant drug test result, repeat testing is indicated, but in the absence of unexpected results (illicit drugs, non-prescribed opioids, non-prescribed benzodiazepines, etc) testing monthly is simply a scam by pain clinics. Perhaps worst of all, is the use of urine drug screening and instrument confirmation when no medications are to be prescribed, administered or dispensed.
2. Genomic testing. Testing of patients may occur on the first visit by using a swab of the cheek to obtain cells that are analyzed to determine the pathways for metabolism of drugs. While theoretically useful, there are no studies after 10 years of availability of these tests showing them to make any difference in outcomes when prescribing opioid narcotics or other drugs, with the exception of psychiatric drugs in the pediatric population. Pain clinics use these tests to make themselves seem "high tech" when in reality, they may be receiving kickbacks from the manufacturer for such tests, that have effectively no usefulness in improving patient outcomes.
3. Forcing patients to have procedures in the pain physician owned surgery center. If your insurance covers hospitals or other surgery centers where the pain physician has privileges but does not cover the pain physician's owned surgery center, then you have the right to insist on having the procedures done elsewhere. If your insurance is not in network with the pain physician's owned surgery center, you may be forced to pay thousands of dollars out of pocket. This is a common scam where pain physician's surgery centers are intentionally out of network so they can financially rape patients. If your pain physician will not agree to do the procedure in an insurance covered facility, then find another pain physician.
4. Last minute notification to bring hundreds or thousands of dollars with you before a procedure. Surgery centers out of network will sometimes wait until the night before, then call the patient demanding they bring cash or a check or credit card to cover a $500-3000 charge that they will incur for having the procedure in an out of network facility. If you don't bring the money, they cancel your procedure and do not give you any other options.
5. Experimental procedures without notifying you of such. Many procedures are not covered by insurance due to their newness or because insurers consider them "investigational" since there is a lack of evidence of efficacy. Some pain clinics will perform such procedures, only later telling you that you must pay out of pocket the entire cost since insurance has denied coverage. The physician knew in advance that coverage would be denied, but did not tell the patient this.
6. Out of network stacked billings. A pain physician may know their facility is out of network, then does a series of three epidural injections, but waiting until the third one is finished to send the bill for all three at the same time. Some pain physicians charge $2500 for an epidural steroid injection that is out of network that is usually paid at a rate of $200 by insurance in-network. Some patients therefore receive their first bill for $7500 at the end of the epidural steroid injection series, that the pain clinic "graciously" allows them to pay off over years.
7. Unnecessary procedures. Patients may have a simple back muscle strain but a pain clinic may subject them to a battery of spinal injections that cannot possibly help the low back strain. There may accumulate tens of thousands of dollars in charges for these injections due to intentional misdiagnosis and documentation of a physical exam that is not at all consistent with the patient's physical exam.
8. Diagnostic procedures with limited evidence of effectiveness but result in a kickback to the pain physician. Some of these tests include surface EMG testing that has been discredited by the American Academy of Neurology, the experts in the field. Other tests that have limited diagnostic capabilities are diagnostic spinal ultrasound, frequently performed by unscrupulous chiropractors and pain physicians and functional range of motion testing or vertebral spine spacing testing.
9. Unnecessary add-ons to injections. Some unscrupulous pain physicians will add on SSEP or EMG testing during simple injection procedures to tell them if they have speared a nerve. These are unnecessary expenses that yield a kick back to the pain clinic for usage, and have never been demonstrated to be effective in the prevention of injury from injections. Some physicians inappropriately insist on routine sedation for procedures in the absence of patient input. While routine sedation is mostly unnecessary, such use results in escalated charges to the patient, some of which may not be covered by insurance, and may result in patients having to pay out of pocket.
10. Physician arrangement with compounding pharmacies or other pharmacies. If a physician tells you to use a specific compounding pharmacy for topical creams, the physician may be receiving kick backs from the pharmacy that overcharges patients. This common arrangement has resulted in many physicians being indicted for defrauding patients and insurance. At other times, physicians will own part of a retail pharmacy, and will refer patients to that pharmacy that may charge patients a higher price than they would pay elsewhere. This is effectively a kickback. Some physicians own in-house pharmacies that dispense drugs for profit. These should be avoided unless you are required to do so by workman's comp or other insurance carrier.
11. Physician sale of durable medical equipment (DME) to patients. Frequently pain physicians will sell back braces, splints, shoe inserts, etc. to patients and the physician is making a killing off of the income they receive from these. Many of the indications are questionable, for instance back braces have very little evidence of effectiveness, and the back brace costing $28 from Walmart may be just as effective as the $700 brace sold at the physician's office. Avoid DME purchases from physician's offices.
12. Vitamin, supplements, magnets sales. These may be sold in the pain clinic at a steep markup by physicians, and have little place in the treatment of chronic pain. No matter how "pure" or "effective" the physician says the vitamins and supplements are, the physician really has no idea since most of the ingredients come from China and are compounded in the US, without adequate analysis of content. Static magnets are simply scams that have little use in pain medicine.
13. Electronic skin and muscle stimulators. While these do have some benefit, those sold in physician's offices at a premium have no more usefulness than those sold on Amazon. Avoid buying equipment from physician's offices since they are making a tidy profit from such sales.
14. Spinal traction. Physicians may own a machine they purchased years ago to deliver spinal traction. They claim they can isolate one segment for preferential traction- an assertion that has found to be impossible when simple physics are applied. Pain clinics may claim they cure disc herniations when in fact, disc herniations usually cure themselves over time, and the traction has no impact at all on the resolution. Frequently they offer a "package price" of 10-20 treatments costing up to $2000. Avoid these scams.
15. Receiving Narcotic Painkillers in trade for Injections. This is one of the most dangerous and insidious practices of pain clinics- to prescribe opioid painkillers only when patients agree to continued injections, and discontinuation of these drugs once the patient no longer wants or is eligible for procedures. Patients may have no alternatives to continued the use of the drugs that they have become chemically dependent on thanks to the pain physician, and sometimes turn to buying prescription painkillers on the street or convert to heroin. Ask up front about the prescription painkillers in case the injections/procedures do not work.
16. Inappropriate use of midlevel practitioners. The least desirable pain clinics are those where the first day's consultation is with a midlevel (CRNA, nurse practitioner, physician's assistant) and medical diagnoses are made in the absence of seeing a physician. Midlevels have effectively no training in the diagnosis and treatment of chronic pain during their education, and therefore are trained "on the job", via a couple of weekend courses, or self-taught by reading short monographs. While midlevels may have a place in the management of pain, they are ill equipped to make an initial diagnosis in pain in the absence of the direct involvement of a physician. At times, these midlevels will be allowed by the pain physician to inappropriately perform spinal injections or procedures on patients. This is both foolish and dangerous. Finally, some midlevels are simply used as drug dealers, with patients agreeing to undergo procedures as a quid pro quo for their midlevel providers dispensing narcotic painkillers.
1. Frequent urine drug screens with confirmation using an in-house analyzer. Urine drug screens may be performed using a dip stick cup costing between $5 and $10. However due to errors in some of the results and the lack of quantitation, doctors began sending in urine specimens to confirmation laboratories. These labs would charge up to $2000 for a confirmation analysis, and with insurance companies balking at paying such high rates, the patients were left paying the balance over months to years. Pain physicians quickly realized by purchasing a $30,000-$200,000 machine to do the same thing, they could capture all this lost revenue previously being paid by patients and insurance to external diagnostic laboratories. However, the amount of testing increased significantly after physicians acquired their own in-house analyzers. Instead of occasionally testing patients, the tests could be as frequent as every office visit with charges to the insurers for many unnecessary tests. Of course if a patient has an aberrant drug test result, repeat testing is indicated, but in the absence of unexpected results (illicit drugs, non-prescribed opioids, non-prescribed benzodiazepines, etc) testing monthly is simply a scam by pain clinics. Perhaps worst of all, is the use of urine drug screening and instrument confirmation when no medications are to be prescribed, administered or dispensed.
2. Genomic testing. Testing of patients may occur on the first visit by using a swab of the cheek to obtain cells that are analyzed to determine the pathways for metabolism of drugs. While theoretically useful, there are no studies after 10 years of availability of these tests showing them to make any difference in outcomes when prescribing opioid narcotics or other drugs, with the exception of psychiatric drugs in the pediatric population. Pain clinics use these tests to make themselves seem "high tech" when in reality, they may be receiving kickbacks from the manufacturer for such tests, that have effectively no usefulness in improving patient outcomes.
3. Forcing patients to have procedures in the pain physician owned surgery center. If your insurance covers hospitals or other surgery centers where the pain physician has privileges but does not cover the pain physician's owned surgery center, then you have the right to insist on having the procedures done elsewhere. If your insurance is not in network with the pain physician's owned surgery center, you may be forced to pay thousands of dollars out of pocket. This is a common scam where pain physician's surgery centers are intentionally out of network so they can financially rape patients. If your pain physician will not agree to do the procedure in an insurance covered facility, then find another pain physician.
4. Last minute notification to bring hundreds or thousands of dollars with you before a procedure. Surgery centers out of network will sometimes wait until the night before, then call the patient demanding they bring cash or a check or credit card to cover a $500-3000 charge that they will incur for having the procedure in an out of network facility. If you don't bring the money, they cancel your procedure and do not give you any other options.
5. Experimental procedures without notifying you of such. Many procedures are not covered by insurance due to their newness or because insurers consider them "investigational" since there is a lack of evidence of efficacy. Some pain clinics will perform such procedures, only later telling you that you must pay out of pocket the entire cost since insurance has denied coverage. The physician knew in advance that coverage would be denied, but did not tell the patient this.
6. Out of network stacked billings. A pain physician may know their facility is out of network, then does a series of three epidural injections, but waiting until the third one is finished to send the bill for all three at the same time. Some pain physicians charge $2500 for an epidural steroid injection that is out of network that is usually paid at a rate of $200 by insurance in-network. Some patients therefore receive their first bill for $7500 at the end of the epidural steroid injection series, that the pain clinic "graciously" allows them to pay off over years.
7. Unnecessary procedures. Patients may have a simple back muscle strain but a pain clinic may subject them to a battery of spinal injections that cannot possibly help the low back strain. There may accumulate tens of thousands of dollars in charges for these injections due to intentional misdiagnosis and documentation of a physical exam that is not at all consistent with the patient's physical exam.
8. Diagnostic procedures with limited evidence of effectiveness but result in a kickback to the pain physician. Some of these tests include surface EMG testing that has been discredited by the American Academy of Neurology, the experts in the field. Other tests that have limited diagnostic capabilities are diagnostic spinal ultrasound, frequently performed by unscrupulous chiropractors and pain physicians and functional range of motion testing or vertebral spine spacing testing.
9. Unnecessary add-ons to injections. Some unscrupulous pain physicians will add on SSEP or EMG testing during simple injection procedures to tell them if they have speared a nerve. These are unnecessary expenses that yield a kick back to the pain clinic for usage, and have never been demonstrated to be effective in the prevention of injury from injections. Some physicians inappropriately insist on routine sedation for procedures in the absence of patient input. While routine sedation is mostly unnecessary, such use results in escalated charges to the patient, some of which may not be covered by insurance, and may result in patients having to pay out of pocket.
10. Physician arrangement with compounding pharmacies or other pharmacies. If a physician tells you to use a specific compounding pharmacy for topical creams, the physician may be receiving kick backs from the pharmacy that overcharges patients. This common arrangement has resulted in many physicians being indicted for defrauding patients and insurance. At other times, physicians will own part of a retail pharmacy, and will refer patients to that pharmacy that may charge patients a higher price than they would pay elsewhere. This is effectively a kickback. Some physicians own in-house pharmacies that dispense drugs for profit. These should be avoided unless you are required to do so by workman's comp or other insurance carrier.
11. Physician sale of durable medical equipment (DME) to patients. Frequently pain physicians will sell back braces, splints, shoe inserts, etc. to patients and the physician is making a killing off of the income they receive from these. Many of the indications are questionable, for instance back braces have very little evidence of effectiveness, and the back brace costing $28 from Walmart may be just as effective as the $700 brace sold at the physician's office. Avoid DME purchases from physician's offices.
12. Vitamin, supplements, magnets sales. These may be sold in the pain clinic at a steep markup by physicians, and have little place in the treatment of chronic pain. No matter how "pure" or "effective" the physician says the vitamins and supplements are, the physician really has no idea since most of the ingredients come from China and are compounded in the US, without adequate analysis of content. Static magnets are simply scams that have little use in pain medicine.
13. Electronic skin and muscle stimulators. While these do have some benefit, those sold in physician's offices at a premium have no more usefulness than those sold on Amazon. Avoid buying equipment from physician's offices since they are making a tidy profit from such sales.
14. Spinal traction. Physicians may own a machine they purchased years ago to deliver spinal traction. They claim they can isolate one segment for preferential traction- an assertion that has found to be impossible when simple physics are applied. Pain clinics may claim they cure disc herniations when in fact, disc herniations usually cure themselves over time, and the traction has no impact at all on the resolution. Frequently they offer a "package price" of 10-20 treatments costing up to $2000. Avoid these scams.
15. Receiving Narcotic Painkillers in trade for Injections. This is one of the most dangerous and insidious practices of pain clinics- to prescribe opioid painkillers only when patients agree to continued injections, and discontinuation of these drugs once the patient no longer wants or is eligible for procedures. Patients may have no alternatives to continued the use of the drugs that they have become chemically dependent on thanks to the pain physician, and sometimes turn to buying prescription painkillers on the street or convert to heroin. Ask up front about the prescription painkillers in case the injections/procedures do not work.
16. Inappropriate use of midlevel practitioners. The least desirable pain clinics are those where the first day's consultation is with a midlevel (CRNA, nurse practitioner, physician's assistant) and medical diagnoses are made in the absence of seeing a physician. Midlevels have effectively no training in the diagnosis and treatment of chronic pain during their education, and therefore are trained "on the job", via a couple of weekend courses, or self-taught by reading short monographs. While midlevels may have a place in the management of pain, they are ill equipped to make an initial diagnosis in pain in the absence of the direct involvement of a physician. At times, these midlevels will be allowed by the pain physician to inappropriately perform spinal injections or procedures on patients. This is both foolish and dangerous. Finally, some midlevels are simply used as drug dealers, with patients agreeing to undergo procedures as a quid pro quo for their midlevel providers dispensing narcotic painkillers.
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