Overview
During our audit period, Dr. Berman improperly billed MassHealth a total of $75,261 for 7,129 quantitative drug tests ordered on the same dates she ordered qualitative drug screens for the same members. MassHealth has not allowed this type of billing since 2013 because it believes the practice is a form of unbundling. For example, a provider of SUD treatment typically orders a less expensive, qualitative drug screen to detect the presence or absence of illicit drugs in a member’s sample. A positive or negative result suffices in this case. Providers who routinely require members to receive multiple, more expensive quantitative drug tests, or combinations of qualitative drug screens and quantitative drug tests, may be ordering testing that is not needed for member treatment and that represents an excessive, unallowable cost to the Commonwealth.13
Authoritative Guidance
Unbundling is prohibited by 130 CMR 450.307:
A. No provider may claim payment in a way that may result in payment that exceeds the maximum allowable amount payable for such service under the applicable payment method.
B. Without limiting the generality of 130 CMR 450.307(A), the following billing practices are forbidden . . .
(2) overstating or misrepresenting services, including submitting separate claims for services [in this case, quantitative drug test procedure codes] or procedures provided as components of a more-comprehensive service [in this case, a qualitative drug screen procedure code] for which a single rate of payment is established.
Further, MassHealth has issued Physician Bulletin 94, dated February 2013, to inform providers that billing for both qualitative drug screens and quantitative drug tests on the same day is not allowed and will be denied by newly modified claim payment system edits:
MassHealth has established new claim edits for quantitative drug tests billed on the same date of service (DOS) as a drug screen service effective for dates of service on or after January 1, 2013.
Quantitative drug tests billed on the same DOS as a drug screen service will be denied with explanation of benefits (EOB) code 8304 (lab conflict w/each other on the same day).
Reasons for Overpayments
Dr. Berman could not explain why she improperly billed MassHealth for quantitative drug tests ordered on the same day as qualitative drug screens.
Recommendations
- Dr. Berman should cease ordering quantitative drug tests and qualitative drug screens for the same MassHealth member on the same day.
- Dr. Berman should collaborate with MassHealth to determine the appropriate amount to be repaid, which should be at least $75,261.
MassHealth’s Response
MassHealth agrees with this finding. MassHealth implemented claim edits in January 2013 and further amended in August 2015 to prevent providers from getting paid for quantitative drug tests performed on the same date of service as qualitative drug screens. . . .
MassHealth will recover any overpayments related to this finding after the auditor’s final report has been issued.
Auditee’s Response
Currently, when ordering drug testing, NECPAD follows the MassHealth recommendations for Medicaid Claims for Drug Screenings, (http://www.mass.gov/auditor/docs/audits/2013/201213743c.pdf) and CMS guidelines (LCD L36037).
Since the drug screen is just a presumptive test, it is clinically necessary to conduct confirmatory testing. CMS specifically warns that at no time a test performed by an [immunoassay, a laboratory test that measures the presence and concentration of a substance within a sample] analyzer should be considered confirmatory. See Local Coverage Determination L36037.
Presumptive drug testing is associated with various limitations as recognized by CMS:
Presumptive UDT testing is limited due to:
- Primarily screens for drug classes rather than specific drugs, and therefore, the practitioner may not be able to determine if a different drug within the same class is causing the positive result;
- Produces erroneous results due to cross-reactivity with other compounds or does not detect all drugs within a drug class;
- Given that not all prescription medications or synthetic/analog drugs are detectable and/or have assays available, it is unclear as to whether other drugs are present when some tests are reported as positive;
- Cut-off may be too high to detect presence of a drug.
This information could cause a practitioner to make an erroneous assumption or clinical decision.
LCD L36037. CMS further advises:
Presumptive UDT may be ordered by the clinician caring for a beneficiary when it is necessary to rapidly obtain and/or integrate results into clinical assessment and treatment decisions. Definitive UDT is reasonable and necessary for the following circumstances:
- Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT;
- Definitively identify specific drugs in a large family of drugs;
- Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, meperidine, synthetic cannabinoids and other synthetic/analog drugs;
- Identify drugs when a definitive concentration of a drug is needed to guide management (e.g., discontinuation of [tetrahydrocannabinol] use according to a treatment plan);
- Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patient’s self-report, presentation, medical history, or current prescribed pain medication plan;
- Rule out an error as the cause of a presumptive UDT result;
- Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and
- Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions.
Definitive UDT may be reasonable and necessary based on patient specific indications, including historical use, medication response, and clinical assessment, when accurate results are necessary to make clinical decisions. The clinician’s rationale for the definitive UDT and the tests ordered must be documented in the patient’s medical record. . . .
A misinterpretation of presumptive results could irreversibly affect the life of a patient, especially when the patient is on probation or is having child custody issues. An example of the negative effects of relying solely on presumptive drug tests follows: a young client on Suboxone came to NECPAD from another provider because her child was taken away from her shortly after the child was born. The Massachusetts Department of Children and Families (DCF) took the child away from her immediately after birth because her test came positive for methadone. The test was a presumptive drug screen done in the doctor’s office. After evaluating the patient’s history, we determined that she had been treated with Suboxone and that she had recently begun using diphenhydramine. Diphenhydramine can cause false positive results for methadone. After enrolling into our program, she complied with all random appointments, which included drug testing, pill count, and individual and group therapy. The NECPAD team worked with DCF to provide updates about the patient’s progress and provided documentation to demonstrate the diphenhydramine drug testing interference that could cause false positive results for Methadone. She and her boyfriend were able to get her newborn back after several weeks. This is just an example of how not performing clinically necessary confirmatory tests could affect patients’ lives.
Due to the nature of the services NECPAD provides, it is clinically necessary to conduct definitive testing. Dr. Berman orders drug testing based on each individual patient’s history and presumptive drug test results. Dr. Berman disputes that the “combination of drug screens and quantitative drug tests, may be . . . testing that is not needed for member treatment.” The definitive drug test results are a critical component of the treatment that NECPAD provides.
Auditor’s Reply
Dr. Berman’s legal counsel states that NECPAD follows MassHealth recommendations for Medicaid claims for drug screenings, referring to a 2013 OSA audit on laboratory drug tests. However, this OSA audit resulted in MassHealth’s creation of an edit in its claim-processing system that disallows payment for exactly the type of drug testing OSA is questioning in this finding. Specifically, as of February 2013, MassHealth no longer allows laboratories or physicians to bill and be paid for definitive drug tests for a member who also receives a presumptive drug screen on the same day. MassHealth disallowed this type of drug testing because it determined that definitive drug tests were not necessary when a presumptive drug screen was medically sufficient and because it believed the practice was a form of unbundling.
Dr. Berman’s legal counsel states that NECPAD also follows the CMS document Local Coverage Determination (LCD): Urine Drug Testing L36037 when ordering and billing for drug tests and further states that presumptive14 urine drug screens are limited and may cause practitioners to make erroneous decisions. However, this CMS document states that definitive testing15 (rather than presumptive) is only necessary when the test’s prescriber needs to know the quantity of a specific substance in a member’s urine sample:
Presumptive UDT may be ordered by the clinician caring for a beneficiary when it is necessary to rapidly obtain and/or integrate results into clinical assessment and treatment decisions.
During our audit, Dr. Berman provided us with her treatment protocols and policies, which state that patients are drug tested to determine whether they are abstaining from illicit substances. According to guidelines from the federal Substance Abuse and Mental Health Administration and the American Society of Addiction Medicine, a presumptive drug screen that identifies the presence or absence of a drug is more appropriate for treating patients who have SUDs.
Dr. Berman’s legal counsel outlines eight circumstances from LCD L36037 and asserts that the circumstances prove that definitive drug tests are reasonable and necessary for Dr. Berman to bill. However, as stated above, this type of drug testing is not practical for treating patients who have SUDs because SUD treatment providers are primarily concerned with the presence, rather than the quantity, of illicit drugs and with obtaining the results quickly. Obtaining results for definitive drug tests takes longer than obtaining results for presumptive drug screens, and as previously noted, MassHealth does not pay for definitive tests performed on the same day as presumptive tests. Therefore, Dr. Berman should not bill this way for these services.
| Date published: | November 14, 2018 |
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