Enforcement Trends: CMS Looks to Recover $66.3 Million in Improper Specimen Validity Test Payments

The opioid crackdown has made urine drug testing an even greater priority for federal health fraud enforcers. One principle target is specimen validity testing (SVT) billed in combination with urine drug tests. In February 2018, the OIG issued a report saying that Medicare made $66.3 million worth of improper payments for such tests and calling on CMS to get that money back. Rather than waiting to hear from their Medicare contractor, a number of labs have stepped up and voluntarily self-disclosed receiving improper payments for SVTs.

Urine Drug & Specimen Validity Testing
SVT analyzes the urine specimen to ensure that it hasn’t been tampered with or adulterated. While Medicare deems urine drug testing medically necessary to detect and quantify the presence of drugs in a patient’s body, SVT is not considered medically necessary if its sole purpose is to validate the specimen since the test results aren’t actually being used to manage the patient’s treatment.

Exception: SVT is medically necessary in limited cases when it’s used in combination with a urine drug test done on the same day for purposes of diagnosing certain conditions such as kidney stones or urinary tract infection. However, the latter cases are relatively rare; or at least CMS thinks they should be. So why are they being billed so frequently?

Indications of Improper Billing
With that question in mind, the OIG audited $67+ million in Medicare Part B payments for SVTs billed in combination with urine drug tests, i.e., on the same dates of service, from 2014 through 2016. The findings: $66.3 million of the payments were improper. Those payments were received by 4,480 clinical labs and physician offices. The OIG report cited two reasons for the improper payments:

  • Providers’ failure to follow existing Medicare guidance; and
  • The inadequacy of CMS system edits designed to prevent payment for SVTs billed in combination with urine drug tests, in spite of revised edits implemented in 2016.

The OIG urged Medicare contractors who made the $66.3 million in improper payments to implement better edits and make an effort to recover the money already spent.

The Fallout
Many of the 4,480 labs and physician offices that received improper SVT payments have gotten a repayment request from their Medicare contractor. But for contractors, recovery isn’t that simple. One problem is that the audit looks only at specific claim lines. Consequently, contractors must conduct medical review of the entire claim to determine whether it includes a relevant diagnosis code.

Meanwhile, some labs have decided to do their own internal audits and voluntarily self-disclose any improper SVT payments they identify. There have been at least two such reported self-disclosure cases in the past month, each totaling six figures:

  • $126,799 paid by The Northern Kentucky Center for Pain Relief (Jan. 24, 2019); and
  • $111,706 paid by Wheelersburg Internal Medicine Group + Mohammad Mouhib Kalo, MD in Ohio (Feb. 6, 2019).

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